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SAJOUS’S 

Analytic Cyclopedia 

OF 

Practical Medicine 


BY 

CHARLES E. de M. SAJOUS, M.D., LL.D., Sc.D. 
>1 

ASSISTED BY 

LOUIS T. de M. SAJOUS. B.S., M.D. 


WITH THE ACTIVE CO-OPERATION OF OVER 

ONE HUNDRED ASSOCIATE EDITORS 


NINTH REVISED EDITION 


1^llu9ttat6^ With ifulUpaoe UDalWone an^ Color plates 
an^ Hpproprlate Cuts In tbe Cext 


VOLUME One 



PHILADELPHIA 

F. A. DAVIS COMPANY, PUBLISHERS 
1922 




COPYRIGHT. 1922 

BY 

F. A. DAVIS COMPANY 
Copyright, Great Britain. All Rights Reserved 









/ 


©C1.A680619 


PRINTED IN U. S. A. 
PRESS OF 

F. A. DAVIS COMPANY 
PHILADELPHIA. PA, 


OCT 31 1922 

i 





J 3 M a -z.. 


PREFACE 

TO THE NINTH EDITION 


The preceding edition, as stated in its preface, incorporated the 
new lines of thought opened up, modified or indirectly influenced by 
the war. This applied not only to surgery as generally believed, but 
also practically to every disease to which the human male is heir, 
including various tropical disorders brought to the seat of active opera¬ 
tions by troops and laborers from Asia, Africa, etc., where such dis¬ 
eases prevailed. The aftermath of this great aggregate of clinical 
observations engendered a period of intensive study calculated to estab¬ 
lish on a solid footing the deductions hastily vouchsafed. The present, 
or ninth edition, even though issued but two years after its predecessor, 
has for its purpose to present what suggestive data of this character 
have been recorded during this brief period. While the majority of 
subjects reviewed in the work have been more or less added to or 
altered, some have required considerable readjustment, those of Frac¬ 
tures and Dislocations for instance, which have been brought up to 
date by Professor W. Wayne Babcock who, as Lieutenant-Colonel and 
Chief Surgeon of one of the greatest of our military hospitals during 
the war, treated an enormous number of injuries of all sorts. 

It was also suggested in the previous edition that as much of the 
material incorporated therein might ultimately have to be modified 
through elucidative inquiry carried on after the excitement accom¬ 
panying or immediately following strife had been allayed, the newer 
data presented at the time had been introduced in small type, the 
larger type text being intended only to portray those features of our 
knowledge which prolonged experience in practice had sanctioned. In 
the short space of two years, the data thus poised on a permanent 
foundation may be said to have been few, but wherever this seemed 
warranted, they, were introduced in the large type text. In some 

(iii) 


IV 


PREFACE. 


directions other than those connected with the war, as in the manage¬ 
ment of the disorders of parturition, the endocrinopathies, protein 
sensitization, protein therapy, adenoid vegetations, etc., greater latitude 
was afforded and taken advantage of. 

The transitions in all branches of medicine are so numerous that 
the value of the present edition will be perpetuated by periodical sup¬ 
plements which, following up each clue in the eight volumes, will enable 
their readers to keep well abreast of the times without being obliged 
to purchase a new Cyclopedia. 


C. E. DE M. Sajous. 


CONTRIBUTORS TO VOLUME I. 


ROBERT T. MORRIS, M.D., 

Professor of Surgery, Post-Graduate Medical School, 

New York City. 

ERNEST LAPLACE, M.D., LL.D., 

Professor of Surgery, University of Pennsylvania Graduate Medical School, 
Philadelphia, Pa. 

A. H. WRIGHT, B.A., M.D., 

Late Professor of Obstetrics, University of Toronto, 

Toronto, Ont. 

JOHN B. DEAVER, M.D., 

Professor of Ginical Surgery, University of Pennsylvania Medical School, 
Philadelphia, Pa. 

FRANCIS X. DERCUM. M.D., 

Professor of Nervous and Mental Diseases, Jefferson Medical College, 
Philadelphia, Pa. 

JAY F. SCHAMBERG, A.B., M.D., 

Professor of Dermatology, Jefferson Medical College, 
Philadelphia, Pa. 

P. E. LAUN0IS,'M.D., Sc.D., 

Professor Agregie of Medicine in the Faculty of Paris, 

AND 

M. H. CESBRON, M.D., 

Paris, France. 

RUFUS B. SCARLETT, M.D., 

Formerly Assistant Physician in the Department of Laryngology, University 
of Pennsylvania Medical School, 

Trenton, N. J. 

J. P. LANGLOIS, M D., 

Professor Agrege of Medicine in the Faculty of Paris, 

Paris, France. 

W. WAYNE BABCOCK, A M., M.D., 

Professor of Surgery and Clinical Surgery, Temple University Medical School, 

Philadelphia, Pa. 


(v) 


VI 


CONTRIBUTORS TO VOLUME L 


FREDERICK P. HENRY, A.M., M.D., 

Professor of Medicine, Woman’s Medical College, 

Philadelphia, Pa. 

AND 

NORMAN P. HENRY, M.D., 

Physician to Pennsylvania Hospital, 

Philadelphia, Pa. 

HOWARD S. HANSELL, M.D., 

Professor of Ophthalmology, Jefferson Medical College, 
Philadelphia, Pa. 

HERMAN F. VICKERY, M.D., 

Assistant Professor of Medicine, Harvard University Medical School, 
Boston, Mass. 

HENRY D. JUMP, M.D., 

Visiting Physician to Philadelphia General and Misericordia Hospitals, 
Philadelphia, Pa. 

WALTER L. CARISS, M.D., 

Assistant Instructor in Laryngology, University of Pennsylvania Medical School, 
and Visiting Physician to Presbyterian Hospital, 

Philadelphia, Pa. 

F. LEVISON, M.D., and A. ERLANDSEN, M.D., 
Copenhagen, Denmark. 

C. SUMNER WITHERSTINE, M.S., M.D., 

Lecturer on Pharmacology, Temple University Medical School, 
Philadelphia, Pa. 

E. E. MONTGOMERY, M.D., LL.D., 

\ 

Professor of Gynecology, Jefferson Medical College, 

Philadelphia, Pa. 

C. E. DE M. SAJOUS, M.D., LL.D., Sc.D., 

Professor of Applied Endocrinology in the University of Pennsylvania Graduate 
Medical School and of Therapeutics in the Temple University Medical School, 
Philadelphia, Pa. 

L. T. DE M. SAJOUS, B.S., M.D., 

Associate Professor of Pharmacology, Temple University Medical School and 
Instructor in Endocrinology in the University of Pennsylvania 
Graduate Medical School, 

Philadelphia, Pa. 


CONTENTS OF FIRST VOLUME. 


The Fourth Era in Surgery. 

Anteoperative Management . 

Instruments and Apparatus . 

Local Anesthesia . 

Postoperative Treatment . 

Postoperative Complications . 

Shock . 

Meteorism . 

Acute Dilatation of the Stomach .. 
Meteorism Due to Mechanical Ob¬ 
struction of Bowel . 

Colon Bacillus Nephritis . 

Meteorism Due to Extension of 

Peritonitis . 

Poisoning by Bichloride of Mercury 


Properitoneal Hernia. 

Hernia into a Rent in the O 
Perforation of the Bowel 


Secondary Abscess 


Postoperative Psychoses . 
Peritoneal Adhesions .... 
Postoperative Pneumonia 

Pleurisy . 

Fistulae . 


Intestinal Sutures 


Non-obstructive or Atonic Dilata¬ 
tion . 


Typical Operations Upon the Stom¬ 
ach . 


Pyloroplasty (Heinecke-Mikulicz 

Operation) . 

Pyloroplasty by Finney’s (Gould’s) 
Method and Gastroduode- 


1 

Abdomen, Surgery of, Typical Opera¬ 


1 

tions Upon the Stomach (continued). 


3 

Gastrostomy . 

51 

6 

Gastrorrhaphy . 

53 

9 

Gastroplasty . 

53 

10 

Gastrogastrostomy . 

53 

12 

Partial Gastrectomy . 

53 

12 

Complete Gastrectomy . 

56 

13 

Surgical Diseases of the Peritoneum. 

56 

14 

Septic Peritonitis . 

56 


Tuberculous Peritonitis . 

59 

14 

Ascites . 

60 

15 

Omentopexy or Talma-Drummond 



Operation . 

, 61 

16 

Surgery of the Mesentery and 



Omentum . 

61 

17 

Surgical Diseases of the Intestines.. 

62 

18 

Ileus . 

62 

18 

Volvulus . 

63 

18 

Intussusception . 

64 

18 

Typhlitis . 

Meckel’s Diverticulum . 

65 

18 

65 

19 

Colonic Diverticula . 

65 

19 

Wounds, Perforation from Within, 


19 

etc. 

66 

19 

Typical Operations of the Intestine .. 

66 

19 

Enterorrhaphy . 

66 

20 

Enterectomy ... 

67 

20 

Enteroanastomoses . 

68 

21 

Gastroenterostomy. 

69 

21 

Anterior Gastroenterostomy . 

71 

22 

Posterior Gastroenterostomy . 

71 

23 

End-to-end Anastomosis after En¬ 


24 

terectomy . 

74 

25. 

Lateral Anastomosis . 

76 

28 

Suture . 

76 

29 

Enteroexclusion . 

77 

35 

Enterostomy, Jejunostomy, Ileos- 


35 

' tomy . 

78 

38 

Surgery of the Appendix . 

79 

41 

Colostomy . 

81 

41 

Appendicostomy and Cecostomy .... 

87 

43 

Appendicostomy . 

87 

44 

Appendicocecostomy . 

89 

46 

Cecostomy . 

Cecostomy with cin Arrangement 

89 

46 

for Irrigating both the 


47 

Small Intestine and Colon.. 

90 

47 

Enterocolonic Irrigator . 

92 

47 

Indications for Direct Bowel 



Treatment . 

93 

47 

Colectomy . 

94 

47 

Cecectomy . 

95 

48 

Sigmoidectomy . 

Surgical Affections of the Pancreas .. 

96 

49 

96 


Acute Pancreatitis. 

96 

49 

Cancer . 

98 


Cysts . 

98 


Calculi . 

98 

50 

Pancreatotomy .. 

99 






























































































Vlll 


CONTENTS. 


PAGE 

Abdomen, Surgery of, Surgical Affec¬ 


tions of the Pancreas {continued}. 

Pancreatectomy . 99 

Pancreaticotomy . 99 

Simple Pancreaticotomy . 99 

Transfluodenal Pancreaticotomy.. 1(X) 
Pancreaticostomy and Pancrcatico- 

en ter ostomy . 100 

Surgical Affections of the Spleen .... 100 

Abscess . 100 

Cysts . 100 

Splenomegaly . 100 

Floating Spleen . KX) 

Neoplasms . 101 

Typical Operations of the Spleen - 101 

Splenectomy . 101 

Surgical Diseases of the Liver and 

Biliary Passages . 102 

Abscess of the Liver . 102 

Subphrenic Abscess . 10v3 

Cysts of the Liver . 103 

Neoplasms . 103 

Cirrhosis . 103 

Hepatoptosis . 103 

Cholelithiasis . 103 

Cholecystitis . 104 

Obliteration of Bile-passages from 

Without . 104 

Typical Operations on Biliary Passages 

and Liver. 104 

Simple Cystotomy . 105 

Cystostomy with Drainage . 105 

Cystectomy . 105 

Technique . 106 

Choledochotomy . 108 

Cholecystenterostomy .. 110 

Excision of Liver; Hepatectomy ... 110 

Ahdominal Injuries . Ill 

Contusion of the Abdomen . Ill 

Symptoms . Ill 

Diagnosis . 114 

Lesions of the Intestinal Tract .. 114 

Lesions of the Stomach . 116 

Lesions of the Liver . 118 

Lesions of the Gall-bladder and 

Biliary Ducts . •.... 119 

Lesions of the Spleen . 119 

Lesions of the Kidneys. 120 

Prognosis . 122 

Treatment . 123 

Shock . 123 

Reaction . 124 

Intestines ... 126 

Stomach .*.. 126 

Liver . 126 

Spleen . 127 

Kidney . 128 

Bladder. 129 

\^"ounds of the Abdomen . 131 

Non-penetrating Wounds . 131 

Treatment . .•.. 132 

Penetrating Wounds . 133 

Symptoms . 133 

Diagnosis . 134 

Intestines . 134 

Stomach . 135 

Liver . 136 


PAGE 

Abdominal Injuries, Wounds of the Ab¬ 
domen, Penetrating Wounds, Diagnosis 


{continued). 

Spleen . 137 

Kidneys . 137 

Bladder . 138 

Prognosis . 140 

Intestines . 142 

Stomach . 142 

Liver . 143 

Spleen . 143 

Kidneys . 143 

Bladder . 144 

Treatment . 144 

Hemorrhage . 149 

Perforation . 152 

After-treatjnent . 154 

Abortion . 154 

Definition . 154 

Symptoms . 156 

Dangers . 159 

Etiology and Pathogenesis . 160 

Maternal Causes . 160 

Paternal and Fetal Causes . 164 

Prognosis . 164 

Treatment . 164 


Treatment of Threatened Abortion. 164 
Treatment of Inevitable Abortion .. 165 
Treatment of Incomplete Abortion. 171 
Sepsis with Incomplete Abortion. 172 
Treatment of Criminal Abortion .. 174 
Treatment of Patient with “Abort¬ 


ing Habit” . 174 

Aberrant Forms. 174 

Missed Abortion . 174 

Mole . 175 

Hydatiform Mole . 175 

Chorioepithelioma . 176 

Induced Abortion . 176 

Indications . 177 

Methods of Inducing Abortion ..... 180 

Abortion, Tubal . 182 

Definition . 182 

Symptoms . 182 

Complications . 187 

Etiology and Pathogenesis . 188 

Treatment . 191 

Abscess . 195 

Definition . 195 

Varieties . 195 

Etiology . !!!!!!!! 196 

Pathology. 195 

Location (Organ or Tissue In¬ 
volved) . 196 

Acute, or Warm . 197 

Symptoms . 197 

Etiology .; 198 

Pathology . 198 

Differential Diagnosis . 2 CK) 

Prognosis . 200 

Treatment . 200 

General Measures . 200 

Surgical Measures . 205 

Cold, or Tuberculous . 207 

Symptoms . 207 

Pathology .207 

Differential Diagnosis . 208 

















































































































CONTENTS. 


IX 


PAGE 

Abscess, Cold, or Tuberculous {con¬ 
tinued). 

Prognosis . 208 

Surgical Treatment. 208 

Aspiration and Injections. 210 

A. C. E, Mixture. See Chloroform. 

Acetanilide . 210 

Properties . 210 

Hose . 210 

Modes of Administration . 211 

Incompatibles . 212 

Contraindications . 212 

Physiological Action. 213 

Untoward Effects and Acute Poison¬ 
ing . 214 

Treatment of Acute Acetanilide Poi¬ 
soning . 217 

Chronic Acetanilide Poisoning. 218 

Treatment of Chronic Acetanilide 

Poisoning . 218 

Applied Therapeutics of Acetanilide .. 219 

Local Uses . 220 

Acetic Acid . 221 

Properties . 221 

Uses and Dose . 221 

Physiological Action . 221 

Acetic Acid Poisoning . 222 

Treatment of Acetic Acid Poison¬ 
ing . 222 

Therapeutics . 223 

Acetonemia . 224 

Diagnosis . 224 

Etiology . 225 

Treatment . 225 

Acetonuria . 226 

Physiological and Pathological Excre¬ 
tion of Acetone . 226 

Origin and Pathological Significance 
of Acetone, Diacetic Acid, 

and Oxybutyric Acid. 228 

Preliminary Tests for Acetone. 231 

Definite Tests for Acetone . 233 

Acetozone . 237 

Modes of Administration . 237 

Therapeutics . 237 

Acetparamidosalol. See Salophen. 

Acetphenetidin . 237 

Properties . 237 

Dose . 238 

Modes of Administration . 238 

Incompatibilities. 238 

Contraindications .238 

Physiological Action . 238 

Untoward Effects and Poisoning .... 240 
Treatment of Acute Poisoning .... 241 

Chronic Poisoning. 241 

Treatment of Chronic Poisoning ... 242 

Therapeutics . 242 

Acetylene . 244 

Acetylene Poisoning . 244 

Treatment of Acetylene Poisoning .. 245 
Acidity of the Gastric Contents, Tests 

for .. 245 

Acidosis. See Autointoxication. 

Acne . . ..'. 248 

Definition . 248 

Symptoms . 248 


PAGE 

Acne {continued). 

Varieties .. 249 

Etiology . 250 

Pathology . 251 

Diagnosis . 252 

Treatment . 252 

General Treatment . 252 

Local Treatment . 253 

Acne Rosacea . 258 

Definition . 258 

Symptoms . 258 

Etiology . 259 

Pathology . 259 

Diagnosis . *... 260 

Prognosis . 260 

Treatment . 260 

Acne Vaccine. See Bacterial Vaccines. 

Acoin . 263 

Aconite . 263 

Preparations and Dose . 263 

Modes of Administration . 264 

Local Use . 2(A 

Incompatibilities . 265 

Contraindications . 265 

Physiological Action . 265 

Mode of Elimination . 266 

Aconite Poisoning . 266 

Treatment of Aconite Poisoning ... 267 

Therapeutics . 270 

Acrocyanosis. See Vascular System, 
Disorders of, under Acro¬ 
paresthesia. 

Acromegaly: Pierre Marie’s Disease .. 273 

Definition . 273 

Symptomatology . 273 

The Hypophyseal Syndrome . 277 

Course and Duration . 292 

Prognosis . 294 

Diagnosis . 294 

Pathology.i ’.. 296 

Pathogenesis . 302 

Treatment . 305 

Actinomycosis . 311 

Definition . 311 

Symptoms . 311 

Diagnosis . 314 

Etiology . 315 

Pathology. 316 

Inoculation . 317 

Prognosis . 318 

Treatment . 319 

Actol . 321 

Therapeutics . 321 

Acupuncture . 321 

Technique . 321 

Acute Rhinitis, or Acute Coryza . 322 

Symptomatology . 322 

Diagnosis .;. 323 

Etiology . 324 

Pathology .326 

Prognosis . 327 

Treatment . 327 

Addison’s Disease . 332 

Symptoms . 332 

Pathogenesis . 338 

Diagnosis . 344 

Treatment . 3^ 















































































































X 


CONTENTS. 


PAGE 


Adenitis . 350 

Definition . 350 

Varieties . 350 

Acute Adenitis . 350 

Symptoms . 350 

Diagnosis . 351 

Etiology . 352 

Pathology . 353 

Prognosis . 354 

Treatment . 354 

Chronic Adenitis . 355 

Symptoms . 355 

1. General Tuberculous Adenitis. 

• 2. Local Tuberculous Adenitis.. 357 

Diagnosis . 358 

Etiology . 359 

Pathology. 360 

Prognosis . 361 

Treatment . 362 

Adenoid Vegetations . 366 

Definition . 366 

Symptoms and Diagnosis . 367 

Etiology . 371 

Patholo^ . 373 

Prognosis . 373 

Treatment . 375 

After-treatment .•. 387 

Adiposis. See Obesity. 

Adiposis Dolorosa; Dercum’s Disease .. 388 

Definition . 388 

Symptoms and Course . 389 

Etiology . 397 

Pathology . 399 

Diagnosis . 404 

Prognosis . 405 

. Treatment . 405 

Adipositas Cerebralis. See Obesity and 
Acromegaly. 

Adonis Vernalis . 407 

Dose . 408 

Physiological Action . 408 

Incompatibilities . 409 

Contraindications . 409 

Therapeutics . 409 

Adrenalin. See Animal Extracts: 
Adrenals. 

Adrenals, Diseases of the . 410 

The Adrenal Secretion in Pulmonary 

and Tissue Oxidation .... 410 
The Adrenal Secretion in Immunity.. 411 

Classification . 412 

Terminal Hypoadrenia . 413 

Definition . 413 

Pathogenesis and Symptomatology. 413 

Pathology. 415 

Treatment . 417 

Acute Hyperadrenia and Adrenal 

Hemorrhage . 420 

Definition . 420 

Symptomatology and Pathogenesis! 421 

Etiology . 424 

Pathology . 425 

Treatment .428 

Hemorrhagic Pseudocysts of the 

Adrenals .. 429 

Symptoms . 429 

Diagnosis .! 43O 


PAGE 

Adrenals, Diseases of the, Hemorrhagic 
Pseudocysts of the Adrenals (con¬ 


tinued). 

Etiology . 431 

Pathology . 431 

Prognosis . 431 

Treatment . 432 

Functional H3'-poadrenia . 432 

Definition . 432 

Symptomatology and Pathogenesis. 432 


Progressive Hypoadrenia. 442 

Cancer of the Adrenals. 443 

Varieties . 443 

Symptoms . 443 

Diagnosis . 445 

Treatment . 446 

H)rpernephroma . 446 

Symptomatology .. 447 

Malignant Hypernephroma of the 

Adrenals .. 448 

Hypernephroma of the Kidney ...... 450 

Symptomatology .'..450 

Diagnosis .. 452 

Pathology .... 453 

Prognosis . 454 

Treatment . 455 

Adrin. See Animal Extracts: Adrenals. 
Agalactia. See Mammary Gland. 

Agar-Agar. 455 

Agaricin . 455 

Dose . 457 

Physiological Action . 457 

Therapeutics . 457 

Agglutination Test . 458 

Agoraphobia . 460 

Agurin ... 460 

Modes of Administration . 460 

Therapeutics .... 460 

Ainhum . 460 

Definition . 460 

Symptoms . 460 

Etiology .. .. . . 461 

Pathology . 461 

Treatment . 462 

Airol . 462 

Modes of Administration . 462 

Physiological Action .. 462 

Therapeutics . 462 

Albargin . 462 

Therapeutics . 463 

Albuminuria . 463 

Definition . 463 

Physiological Albuminuria . 463 

Physiological Cyclical, Orthostatic, 

and Orthotic Albuminuria .. 467 

Pathological Albuminuria . 470 

Tests . 473 

Treatment .482 

Albumosuria . 483 

Alcohol . 484 

Preparations and Dose . 484 

Modes of Administration . 485 

Contraindications . 488 

Physiological Action .. 489 

Therapeutics . 500 















































































































CONTENTS. 


XI 


PAGE 


Alcoholism, or Alcohol Inebriety . 

Definition . 

Toxicity of the Alcohols . 

Varieties . 

Acute Alcoholism . 

Definition . 

Symptoms . 

Differential Diagnosis . 

Pathology . 

Treatment . 

Chronic Alcoholism . 

Definition . 

Symptoms . 

Diagnosis . 

Patholof^ . 

Prognosis . 

Treatment . 

Acute Alcoholic Delirium, or De¬ 
lirium Tremens . 

Symptoms . 

Diagnosis . 

Patholof^ . 

Prognosis . 

Treatment . 

Acute Alcoholic Mania (Mania a 

Potu) . 

Symptoms . 

Differential Diagnosis . 

Etiology and Pathology . 

Prognosis . 

Treatment. 

Aleppo Boil. See Oriental Sore. 

Aloes . 

Properties and Constituents . 

Dose and Preparations . 

Modes of Administration . 

Tncompatibles . 

Contraindications . 

Physiological Action . 

Untoward Effects . 

Therapeutic Uses . 

Alopecia . 

Definition . 

Congenital Alopecia . 

Senile Alopecia . 

Premature Alopecia . 

Alopecia Seborrhoeica . 

Etiology and Pathology . 

Prognosis . 

Treatment . 

Alopecia Areata . 

Definition . 

Symptoms . 

Etiology . 

Pathology . 

Prognosis . 

Treatment ... 

Alsol. See Aluminum : Aluminum Ace- 
totartrate. 

Alum . 

Dose .. 

Modes of Administration . 

Tncompatibles . 

Contraindications . 

Physiological Action .. 

Untoward Effects and Poisoning. 

Therapeutic Uses . 


511 

511 

512 

513 
513 
513 
513 
515 

517 

518 
520 
520 
520 
523 
525 

525 

526 

533 

533 

534 

534 

535 
535 

539 

539 

539 

539 

540 
540 

540 

540 

541 

541 

542 
542 

542 

543 

543 

544 
544 

544 

545 

545 

546 

547 

548 
548 
551 
551 

551 

552 
554 
554 
554 


556 

556 

556 

557 
557 
557 

557 

558 


PAGE 

Aluminum . 560 

Aluminum Hydroxide . 561 

Aluminum Sulphate . 561 

Aluminum Acetate . 561 

Aluminum Acetotartrate . 562 

Aluminum Boroformate . 563 

Aluminum Borotannate . 563 

Aluminum Borotartrate . 563 

Aluminum Carbonate . 563 

Aluminum Chloride .. 564 

Aluminum Phenolsulphonate . 564 

Aluminim Salicylate . 564 

Aluminum Silicate . S(A 

Alumnol . 564 

Mode of Employment . 564 

Therapeutic Uses . 564 

Alypin . 566 

Untoward Effects . 566 

Alzheimer’s Disease . 566 

Amaurosis . 567 

Definition . 567 

Amaurosis in Brain Disease . 567 

Amaurosis in Nephritis . 567 

Amaurosis in Hysteria .. 568 

Amaurosis in Spinal Disease . 568 

Amaurosis following Hemorrhage. 569 

Amaurosis in Pregnancy . 569 

Amaurosis from Fracture of the 

Skull . 570 

Congenital and Hereditary Amau¬ 
rosis . 570 

Amblyopia . 572 

Definition . 572 

Toxic Amblyopia . 572 

Loss of Vision . 572 

Central. Scotoma . 573 

Papilla Changes . 573 

Acute Poisoning . 573 

Amblyopia from Intracranial Causes. 573 

Hysterical Amblyopia . 574 

Simulated Amblyopia. 574 

Amblyopia Exanopsia . 575 

From Congenital Defects . 575 

From Defects of Refraction - 575 

Amblyopia from Exhaustion . 576 

Amenorrhea . 576 

Definition . 576 

Varieties . 576 

Symptoms . 576 

Etiolo'gy . 577 

Patholo^ . 579 

Diagnosis .•. 579 

Prognosis . 579 

Treatment . 579 

Amidoacetphenetidin Hydrochloride. See 
Phenocoll Hydrochloride. 
Aminoform. See Hexamethylenamine. 

Ammonia .. 581 

Properties . 581 

Preparations and Dose . 582 

Modes of Administration . 582 

Tncompatibles . 583 

Contraindications .. 583 

Physiological Action . 583 

Local Effects . 583 

Effects on Internal Use. 583 

Toxicology . 584 


























































































































Xll 


CONTENTS. 


PAGE 


Ammonia, Toxicology {continued). 

Treatment of Ammonia Poisoning . 585 
Applied Therapeutics of Ammonia .. 585 

Ammonium . 587 

Physiological Action . 588 

Ammonium Acet te . 589 

Mode of Administration . 589 

Incompatibles . 589 

Physiological Action . 589 

Therapeutics . 590 

Ammonium Carbonate . 590 

Modes of Administration . 591 

Incompatibles ..!. 591 

Physiological Action. 591 

Toxicology . 592 

Therapeutics . 592 

Ammonium Chloride . 592 

Modes of Administration. 593 

Incompatibles . 593 

Physiological Action. 599 

Therapeutics . 594 

Ammonium Ichthyol Group. See Ichthyol. 
Amnesia . 596 


Amputations and Resections. See Resec¬ 
tions, Amputations, etc. 


Amyl Nitrite. See Nitrites. 

Amylene Chloral. See Dormiol. 

Amylene Hydrate . 597 

Dose and Modes of Administration .. 597 

Physiological Action . 597 

Untoward Effects; Poisoning . 598 

Therapeutic Uses . 598 

Amyloform . 599 

Physiological ivction . 599 

Therapeutic Uses. 599 

Amyl Valerate . 600 

Physiological Action . 600 

Therapeutic Uses . 600 

Analgen . 600 

Therapeutic Uses . 601 

Symptoms. 601 

Diagnosis and Pathogenesis . 603 

Etiology and Pathology . 604 

Prophylaxis . 605 

Treatment of Anaphylactic Reaction .. 607 

Anemia, Pernicious Progressive . 608 

Definition . 608 

Symptomatology . 608 

Blood Examination . 610 

Pathology . 613 

Diagnosis . 616 

Benign Anemia. 616 

Chlorosis . 616 

Leukemia . 616 

Pseudoleukemia . 616 

Gastric Cancer . 616 

Etiology .’ 617 

Prognosis . 619 

Treatment . 620 

Anemia, Secondary, or Symptomatic .. 626 

Definition . 626 

Types of Secondary Anemia. 627 

Posthemorrhagic Anemias . 627 

Infectious and Toxic Anemias. 627 

Trophic Anemias . 628 


PAGE 

Anemia, Secondary or Symptomatic {con¬ 


tinued). 

Pathology .629 

S;^ptomatology . 632 

Diagnosis . 634 

Prognosis . 636 

Treatment . 636 

Anencephaly . 641 

Anesin. See Chloretone. 

Anesthesia . 642 

Choice of Anesthetics . 642 

Ethyl Chloride . 642 

Chloroform . 642 

Nitrous Oxide . 642 

Ether . 642 

Ether-Oxygen . 642 

Oil-ether Colonic Anesthesia . 643 

Nitrous Oxide Gas . 643 

Preliminary Narcotics . 643 

Miscellaneous Factors.*. 644 

Fright . 644 

Breathing Test to Ascertain Condi¬ 
tion of Heart Muscle . 644 

Pre-anesthetic Diet . 644 

Self-anesthesia in Field . 644 

Heating of Anesthetic . 644 

Trendelenburg Position as Source of 

Danger . 645 

Shock During General Anesthesia ..645 

Post-anesthetic Intoxication . 645 

Post-anesthetic Vomiting . 645 

Effects on the Adrenals of Anes¬ 
thetics . 646 

Untoward Effects of Adrenalin .... 646 
After-effects on Nervous System .. 646 

Narcoanesthesia . 647 

Comparative Merits of Various Local 

Anesthetics . 647 

Anesthesia Acidosis . 648 

Prophylaxis .648 

Anesthesin . 649 

Physiological Action. 649 

Therapeutic Uses . 649 

Aneurism . 650 

Definition . 650 

Varieties . 650 

Etiology. 651 

Pathology . 653 

Symptoms . 655 

Course . 659 

Differential Diagnosis . 659 

Treatment . 660 

Arteriovenous Aneurism . 668 

Aneurismal Varix . 668 

Varicose Aneurism . 668 

Symptoms. 668 

Treatment . 669 

Conditions Related to Aneurisms .... 670 
Angina Ludovici. See Pharynx and 
Tonsils, Diseases of. 

Angina Pectoris .. 670 

Definition . 670 

Symptoms. 670 

Diagnosis . 672 

Intercostal Neuralgia .. 673 











































































































CONTENTS. 


Xlll 


Angina Pectoris, Diagnosis (continued). 

Gastralgia. 673 

Cardiac Asthma. 673 

“Pseiidoangina” . 673 

Hysteria . 674 

Syphilis . 674 

Tobacco, Tea, etc.674 

Etiology . 675 

I\athology. 676 

Prognosis . 680 

Treatment. 680 

Angiomata. See Blood-vessels, Tumors 
of. 


Angioneurotic Edema. See Ascites and 


Edema. 

Anhalonium Lewinii . 685 

Preparations and Dose . 686 

Physiological Action . 686 

Therapeutic Uses. 687 

Anhidrosis, or Anidrosis. See Sweat 
Glands, Diseases of. 

Animal Extracts, or Organotherapy .... 687 

Thyroid Gland Organotherapy. 689 

Physiological Action.690 

Thyroxin.693 

Antitoxic Function .693 

The Active Principle of Thyroid .. 696 

Preparations and Dose . 697 

Untoward Effects and Their Preven¬ 
tion . 698 

Treatment of Thyroid Poisoning ... 698 

Therapeutics . 699 

Hypothyroidia, or Hypothyroid¬ 
ism .. 700 

Hyperthyroidia, or Hyperthyroid¬ 
ism . 704 

Untoward Effects . 706 

Cretinism . 708 

Myxedema . 715 

Obesity . 719 

Miscellaneous Disorders . 722 

Acromegaly . 722 

Arthritis, Chronic Rheumatoid.. 723 

Cancer. 726 

Cutaneous Disorders. 729 

Exophthalmic Goiter or Graves’s 

Disease . 731 

Hemophilia . 731 

Incontinence of Urine . 731 

Infectious Diseases . 731 

Insanity . 732 

Lactation . 733 

Middle-ear Disorders . 733 

Nervous Disorders . 733 

Epilepsy . 733 

Eclampsia. 734 

Migraine. 735 

Asthma . 735 

Tetanus. 735 

Osseous Disorders . 735 

Rheumatism, Chronic Progress¬ 
ive . 736 

Uterine Disorders . 736 

Summary . 737 

Parathyroid Organotherapy . 737 


Animal Extracts, Parathyroid Organo¬ 


therapy (continued). 

Therapeutics .:.. 738 

Adrenal or Suprarenal Organotherapy 740 

Physiological Action . 742 

Preparations and Dose . 745 

Contraindications . 747 

Untoward Effects . 747 

Therapeutics . 750 

Addison’s Disease . 750 

Shock, Collapse, and Surgical Dis¬ 
eases . 751 

Toxemias and Bacterial Infec¬ 
tions . 753 

Postoperative Intestinal Atony .. 756 

Miscellaneous Disorders . 757 

Hemorrhage . 757 

Asthenic Cardiac Disorders with 

Dilatation . 757 

Asthma . 758 

Effusions. 758 

Disorders of Pregnancy and 

Parturition. 758 

Cancer. 758 

Osteomalacia . 759 

Local Uses. 760 

Hemorrhage . 760 

Hemorrhoids. 761 

Neuralgia, Sciatica, and Neu¬ 
ritis . 761 

Cutaneous Disorders . 761 

Pituitary Organotherapy . 761 

Preparations and Dose . 763 

Therapeutics . 7(4 

Acromegaly . 764 

Cardiac Disorders. 764 

Obstetrics . 766 

Infectious Diseases . 769 

Exophthalmic Goiter . 770 

Nervous and Mental Diseases and 

Myopathies . 770 

Stunted Growth and Imbecility .. 771 

Intestinal Paresis . 772 

Orchitic or Testicular Organotherapy; 

Spermin. 773 

Therapeutics . 775 

Ovarian Organotherapy . 775 

Preparations and Doses. 777 

Therapeutics . 777 

Natural and Artificial Menopause. 777 

Corpus Luteum Organotherapy . 778 

Preparations and Doses . 779 

Therapeutics . 779 

Kidney Organotherapy . 783 

Therapeutics and Dose . 783 

Thymus Organotherapy. 784 

Therapeutics . 785 

Diseases of the Thyroid.’785 

Rachitis, or Rickets . 785 

Bone-Marrow Organotherapy. 786 

Brain and Nerve Substance Organo¬ 
therapy . 786 

Mammary Gland Organotherapy .... 787 

Spleen Organotherapy . 788 

Hepatic Organotherapy . 788 

Bile, Bile-Salts, and Biliary Extracts.. 789 






































































































SAJOUS’S 

ANALYTIC CYCLOPEDIA 
of PRACTICAL MEDICINE 


A 


ABDOMEN, SURGERY OF— 

Abdominal surgery in its wide sense 
includes a great variety of operative 
procedures which are based upon the 
same general principles as the ones 
which are included in this article, but 
which have been left to contributors 
in the other departments: all of the 
external hernias, a good part of renal 
surgery, the surgery of the abdominal 
walls, and all of the pelvic surgery of 
the female. 

This article takes account of that 
part of abdominal surgery which in¬ 
cludes hollow and solid viscera, the 
former comprising the various parts 
of the alimentary tube between the 
diaphragm and the brim of the pelvis, 
all biliary and pancreatic ducts and 
the gall-bladder. The solid viscera 
belonging to this series of articles 
comprise the liver, spleen and pan¬ 
creas only. 

There is a general sameness of the 
alimentary canal in these various 
parts which leads to more or less 
correspondence between operations 
done at the diflferent levels of this 
tract. Operations of the biliary ducts 
and gall-bladder also have many 
points in common, and they resemble 
in a way the operative resources that 


are employed for the genitourinary 
passages. 

We propose to consider the spe¬ 
cial features of abdominal surgery in 
two ways: first, as a series of typical 
operations which are intended to cor¬ 
rect certain diseased states, and then 
from the other direction as a series of 
diseased states to be relieved by 
operative procedures of various kinds. 
It seems therefore of advantage to 
consider the typical operations for the 
stomach, small and large intestines and 
biliary passages as operations which 
are in a way applicable to all surgical 
conditions of these organs. Surgical 
diseases of the peritoneum, appendix, 
liver, spleen and pancreas require 
separate consideration in detail, be¬ 
cause of the relative absence of typi¬ 
cal operations, making the treatment 
more or less individualized for each 
case. 

THE FOURTH ERA IN SUR¬ 
GERY. —In abdominal surgery we 
have perhaps the best field for object 
lessons relative to the new fourth or 
physiologic era in surgery. The first 
era in surgery was the heroic, under 
which practically no abdominal sur¬ 
gery was done. In the second or 
anatomic era of surgery, abdominal 




2 


ABDOMEN, SURGERY OF (MORRIS). 


operations were in general so danger¬ 
ous that few were attempted, except¬ 
ing in cases of great emergency, and 
usually with a fatal ending. The 
third or pathologic era of surgery was 
based upon the studies of Pasteur and 
of Lister. Aside from its technique 
of preventing the development of bac¬ 
teria in wounds, it included the idea 
of removing all products of infection 
with painstaking care. 

Notwithstanding the injury that 
was done to patients by surgeons 
carrying out the principles of this era, 
abdominal surgery made its first great 
advances. Detailed attention was 
given to the deliberate disposal of 
products of infection found within the 
peritoneal cavity, and little or no at¬ 
tention was paid to the natural re¬ 
sistance forces contained within the 
patient himself. There was an enor¬ 
mous waste of such forces, in fact, in 
our abdominal surgery of the patho¬ 
logic era. 

The entirely modern or physiologic 
era is based upon the studies of 
Metchnikoff and Wright, and includes 
the principal idea of allowing the 
patient to retain his natural forces 
in such a way as to gain control of 
infections. Metchnikoff and his fol¬ 
lowers taught us that certain cells of 
the blood and lymph circulatory sys¬ 
tems not only disposed of bacteria 
daily under normal conditions, but 
that these cells were increased in 
number rapidly to meet emergen¬ 
cies of infection. These investigators 
showed also that bacteria were de¬ 
stroyed by certain fixed body cells. 
Wright and his followers showed fur¬ 
ther that, in the presence of an infec¬ 
tion, several kinds of antibodies were 
elaborated in the animal economy, 
and these antibodies lent their aid in 


removing infections and in destroy¬ 
ing certain toxins that were produced 
by bacteria. The principles of this 
fourth or physiologic era of surgery 
brought us face to face with the 
problem of operating in such a way 
as to leave the patient in the very 
best condition for managing infec¬ 
tions himself with his own phagocytes 
and antibodies, and led to a revolu¬ 
tion in methods, forcing us to drop 
out of our technique such parts of the 
system of the third or pathologic era 
as interfered with the ability of the 
patient to produce phagocytes and 
antibodies. 

For instance, a prolonged and 
painstaking operation for removing 
all of the pus from the peritoneal 
cavity so shocked the great vaso¬ 
motor centers of the patient that they 
were palsied, and unable promptly to 
take up the work of conducting the 
manufacture of phagocytes and anti¬ 
bodies, with which the patient him¬ 
self could dispose of the products of 
infection much better than the sur¬ 
geon could do it in his crude mechani¬ 
cal way. 

Unnecessarily prolonged operations 
acted in precisely the same way; 
and where we had thought best to 
expend a half-hour in carrying out 
the theories of the pathologic era in 
surgery, we may now expend five 
minutes under the principles of the 
physiologic era. 

Experimentation has shown that shock 
is produced more readily by manipulation 
of the abdominal viscera than by gross in¬ 
juries, when animals are fully anesthetized, 
especially when the anesthetic used is 
chloroform. The parietal peritoneum and 
mesenteries are especially sensitive. These 
facts emphasized some years ago by Mum¬ 
mery and Symes ar now fully recognized. 
Editors. 


ABDOMEN, SURGERY OF (MORRIS). 


3 


A long period of anesthesia was 
commonly required for thorough work 
under the principles of the third era, 
but we now know, from our experi¬ 
ments upon animals, that individuals 
profoundly under the influence of 
alcohol, or of ether or of chloroform, 
temporarily lose resistance to infec¬ 
tions, and some acute infections which 
would not gain headway under a few 
minutes of anesthesia may seize the 
opportunity to gain ascendancy if the 
anesthesia is prolonged for an hour or 
two. Bulky or complicated drainage 
apparatus, acting as a foreign body, 
further produces derangement of func¬ 
tion of the vasomotors in such a way 
as to prevent the patient from manu¬ 
facturing his phagocytes and anti¬ 
bodies. We are just entering, then, 
the era in which! the greatest degree 
of success is to follow our opera¬ 
tive procedures within the abdominal 
cavity. 

ANTEOPERATIVE MANAGE¬ 
MENT. —Aside from the general prin¬ 
ciples which govern the preparation 
of a patient for any major operation, 
certain special requirements are indi¬ 
cated which lessen the operative risk, 
and the tendency to postoperative 
complications in abdominal surgery. 

Postoperative pneumonia, for in¬ 
stance, will occur less often if we 
make careful choice of the anesthetic 
for any given case, and if we make 
this period of anesthesia as short as 
possible, on account of the known 
tendency of some acute infections to 
shoot ahead when the patient is under 
the influence of ether or chloroform. 
Some operators will choose nitrous 
oxide and oxygen in cases in which 
this phenomenon is anticipated. In 
some feeble patients, or patients with 
complications of disease of vital 


organs, spinal anesthesia according to 
the Jonnesco method is desirable. 

Preoperative intestinal asepsis can 
only be approximated, but for most 
practical purposes a good purgative 
given within twenty-four hours of 
operation will suffice. If the stomach 
itself is to be operated upon, further 
steps in the direction of asepsis are 
required, and we wash the stomach 
out very thoroughly with saturated 
boric acid solution just in advance of 
operation. This is done most comfort¬ 
ably, as a rule, after the patient is 
under the influence of the anesthetic, 
and by means of the common siphon 
tube. After the alimentary tract has 
been cleansed by purgatives, it is im¬ 
portant to give only the simplest arti¬ 
cles of food and drink in advance of 
the operation, but we must avoid hav¬ 
ing a patient abstain in such a way 
as to become unduly weakened. Pa¬ 
tients who are accustomed to dieting 
may sometimes be placed on special 
diet to advantage for a few days in 
advance of operation, but the physical 
effect of placing a patient on diet for 
any length of time is apt to be such 
as to counteract any good effect. 

Special stress has of late been laid 
on carbohydrate starvation as a cause 
of acidosis. It is important that an 
excess of ketone substances, acetone, 
diacetic, and oxybutyric acids (aceto¬ 
nemia, q.v.)y sometimes with increased 
ammonia elimination, should be looked 
for by laboratory tests prior to 
operation. 

The expenditure of muscular en- 
erg-y before, during, and after opera¬ 
tion entails a deficiency of glycogen 
which carbohydrate starvation only 
serves to aggravate, and which mani¬ 
fests itself by acidosis, with dyspnea, 
tachycardia and acetone breath as main 
phenomena. When acetone or di- 


4 


ABDOMEN, SURGERY OF (MORRIS). 


acetic acid is found in the urine in 
such cases, active treatment is indi¬ 
cated. Following Bainbridge’s routine 
preoperative treatment the writer ad¬ 
ministers a purgative and for several 
days milk sugar and also sodium bi¬ 
carbonate by mouth and rectum, to 
reduce the acidity of the urine to nor¬ 
mal limits. In marked acidosis, large 
colonic irrigations of the same salt 6 
to 10 quarts—liters—of a solution, 1 
dram—4 Gm.—to the pint—500 c.c., 
are given daily, for the same purpose. 
Burnham (Amer. Med., Nov., 1916). 

Inability to assimilate carbohydrates 
is best treated by supplying enough 
carbohydrate and by the neutraliza¬ 
tion of acid products with alkali. Sur¬ 
geons must keep their eyes open to 
the dangers of acidosis. Prolonged 
starvation is especially harmful in 
children or those suffering from any 
form of exhaustion. W. A. Lincoln 
(Annals of Surg., Ixv, 135, 1917). 

It is far better to omit the cathar¬ 
tic or prepare the patient according 
to the following plan: Seventy-two 
hours before operation the bowels 
are cleared with castor oil. After 
the cathartic only liquids or food 
that will leave very little residue is 
permitted. In rectal operations, the 
evening before the operation the 
patient is given a high enema of nor¬ 
mal saline solution, and 2 hours be¬ 
fore operation a copious low enema 
of warm saturated boric acid solution, 
Fansler (Jour.-Lancet, Nov., 1920). 

Preoperative Purgation.—This measure 
has recently been condemned by a num¬ 
ber of prominent surgeons, who found its 
omission beneficial owing mainly to the 
fact that a purged bowel is often distended 
with gas and decidedly congested. Sajous 
has pointed out that purgatives sweep 
from the intestinal canal a product termed 
“secretion,” by Starling, which not only 
serves to liberate and activate the pan¬ 
creatic enzymes, but also to promote the 
production of bile and succus entericus. 
Normally, after about 24 hours this tem¬ 
porary deficiency adjusts itself; if, how¬ 
ever, an operation is performed, this re¬ 
adjustment is retarded in proportion with 
the shock involved. Again, Sajous hav¬ 


ing shown that the intestinal enzymes are 
bactericidal and antitoxic, their elimination 
by purgatives tends to favor autointoxica¬ 
tion and fermentation. 

In general a short period, of rest in 
bed before an operation is of advan¬ 
tage, but if this time extends beyond 
twenty-four hours, excepting for pa¬ 
tients who are already in bed with 
some severe abdominal, complication, 
the apprehension and introspection of 
the patient with a negative imagina¬ 
tion in advance of operative proced¬ 
ures may be disastrous, and has even 
gone to the point of allowing the 
patient to develop suicidal impulse. 
For patients who are not already in 
bed from necessity, the author pre¬ 
fers to have as short a period of prep¬ 
aration as expediency would suggest, 
not more than twenty-four hours as 
a rule. There are many instances 
in which the patient needs special 
medical treatment in advance of oper¬ 
ation, because of some defect of the 
heart, lungs, or kidneys, but under 
such circumstances with most pa¬ 
tients it is best not to tell them of the 
date set for operation far in advance, 
up to which they are to be led. 

The prognosis of preoperative 
shock is materially improved if an 
hour or two is allowed for resuscita¬ 
tion prior to operation, during which 
saline solution is given subcutane¬ 
ously or by vein, warmth applied, an 
opiate injected, and camphor in oil 
given subcutaneously if a stimulant 
is required. Prior to operation it is 
well to give omnopon and scopola¬ 
mine. The best anesthetic was found 
to be warm ether and oxygen. Lock- 
wood, Kennedy, Macfie and Charles 
(Brit. Med. Jour., Mar. 10, 1917). 

Anteoperative narcosis is undesir¬ 
able for one chief reason shown by 
Cantacuzene in his experiments with 
animals subjected to the influence of 
opium after infection. This author 


ABDOMEN, SURGERY OF (MORRIS). 


5 


showed that narcotized animals 
rapidly succumbed at the time when 
another series subjected to the same 
infection, but not narcotized, were 
meeting the infection. 

Arrangements should be made be¬ 
forehand for maintaining the animal 
warmth of the patient with woolen 
garments or blankets, and it is best 
to have a good circulation of air in 
the operating room. In an over¬ 
heated operating room with closed 
windows and doors the surgeon him¬ 
self may be extremely uncomfortable, 
and feeling the need for oxygen, and 
we assume that the patient at the 
same time suffers the same depressing 
influence in addition to the shock 
of the operation. Experiments with 
animals have shown that the perito¬ 
neum is not injured by exposure to 
air currents and to low temperature as 
much as it is injured by contact with 
gauze, antiseptic solutions, or by rough 
handling. The author believes that 
the temperature and air circulation of 
the room most agreeable to the sur¬ 
geon is at the same time most benefi¬ 
cial to the patient. Asepsis is to be 
begun where possible before the 
operation with a general bath, and 
particular attention given to the prep¬ 
aration of the umbilical region. 

The skin in the field of operation 
may be well prepared in the common 
way by shaving, then scrubbing with 
green soap, which is washed off with 
a weak bichloride of mercury solution, 
and a pad of gauze wet with this solu¬ 
tion is placed in contact with the 
wound for a few hours. A more re¬ 
cently used and very effective way of 
sterilizing the skin consists in simply 
painting it over with a 2 per cent, solu¬ 
tion of iodine in benzin after shaving. 

The need of aseptic surroundings 


relating to the preparation of the 
operating room need not be discussed 
in this article. Asepsis on the part of 
the operator is met by the wearing of 
a sterile gown and cap and a mouth 
guard of gauze, because with every 
breath, and particularly in the course 
of conversation during an operation, 
bacteria are projected from the mouth 
of the operator over the field of the 
wound. 

The hands and forearms may be 
prepared simply by scrubbing with 
green soarp, and then in a weak solu¬ 
tion of bichloride of mercury. This 
destroys practically all of the bacteria 
which are likely to cause trouble. 
Latent colonies of bacteria which 
work out of the epithelium of the 
hands in the course of an operation 
are generally dormant colonies which 
are managed by the blood-serum or 
tissues of the patient safely. The use 
of rubber gloves in abdominal sur¬ 
gery is particularly undesirable; first, 
because they interfere with the nice 
sense of touch required for separating 
adhesions, or for doing rapid sutur¬ 
ing. The operator wearing rubber 
gloves is apt to require longer inci¬ 
sions which allow him to work by 
sight, and this is not in harmony with 
the principles of the physiologic era 
in surgery. 

The peritoneum protects itself so 
well if given fair opportunity that we 
do not need to apply the extreme 
degree of asepsis that would be 
needed in opening the knee-joint or 
the meninges of the brain, but it is 
well for assistants who are not 
engaged in separating adhesions, or 
in applying sutures, or in hunting for 
structures within the abdomen, to 
wear rubber gloves. One can do a 
much higher class of operative work 


6 


ABDOMEN, SURGERY OF (MORRIS). 


within the peritoneal cavity where 
nice sense of touch is not interfered 
with; and the greater length of time 
required in operating where rubber 
gloves are used and the longer inci¬ 
sions counterbalance the benefit of 
such asepsis as would be gained 
through the use of the gloves. 

It has been shown experimentally 
with Petri plates in the operating 
room that large numbers of bacteria 
are constantly falling into every open 
wound, no matter what precautions 
have been observed in advance. 
These bacteria are for the most part 
disposed of in the patient’s tissues 
and blood- and lymph-vessels; but the 
longer the incision and the greater 
the length of time during which any 
given wound remains open, the more 
bacteria fall into the wound from the 
air. 

If one can work more quickly 
and through shorter incisions with 
bare hands, he naturally makes better 
asepsis of the wound, provided that 
his hands have been well prepared in 
advance. 

Instruments may be sterilized by 
dry heat in the oven, by immersion in 
95 per cent, carbolic acid, or in the 
more common way by boiling in 
water for fifteen minutes. In the 
latter case bicarbonate of soda in the 
proportion of a teaspoonful to a quart 
of water is added to prevent the rust¬ 
ing of instruments. The carbolic acid 
preparation is particularly suitable for 
small, sharp, delicate instruments, 
and does not interfere in any way 
with their edges. The carbolic acid 
which clings to them on removal is 
instantly neutralized by immersion in 
alcohol. 

INSTRUMENTS AND APPA¬ 
RATUS.—Scissors. —There are very 


few intra-abdominal operations which 
cannot be performed from first to last 
with a pair of scissors and a couple 
of needles and no other instruments 
whatsoever. In adding other instru¬ 
ments which give special facility in 
certain operations it is well to remem¬ 
ber this statement, and it will avoid 
the multiplicity of instruments which 
are frequently used to the patient’s 
disadvantage or injury, as may be 
observed often enough. The form of 
scissors which the author prefers is 
the ordinary French locked type, five 
or six inches long, with one sharp 
point and one blunt point, and kept 
very sharp. The preference for scis¬ 
sors over scalpel is based upon the 
fact that small blood-vessels seem to 
ooze much less after division with the 
scissors than with the scalpel. This 
is possibly due to contraction stimu¬ 
lated by the character of the cut made 
by the scissors, but there is no inter¬ 
ference with primary union of the 
tissues subsequently, according to ob¬ 
servations extended over a series of 
years. 

Needles of the Hagedorn type will 
suffice for practically all abdominal 
work, and needles threaded with cat¬ 
gut slipped under bleeding vessels 
readily take the place of the artery 
forceps without loss of time, with a 
rather greater degree of accuracy, 
and with less crushing of tissues. 
For intestinal or gastric suturing the 
author prefers a needle that is con¬ 
siderably larger than the one that is 
commonly used, for the reason that it 
carries a suture of greater diameter, 
and a suture of fairly large diameter 
does not cut out of the tissues so 
readily as an extremely fine suture 
when subjected to tension. The 
custom of using a very fine needle 


ABDOMEN, SURGERY OF (MORRIS). 


7 


and silk is based upon the idea of 
causing the least degree of operative 
damage and avoidance of leaking of 
contents of the hollow viscera, but it 
is not based upon our observations of 
the extent to which the mucous mem¬ 
brane will plug fairly large punctures, 
or our knowledge of the greater secu¬ 
rity of tissues sutured with a strand 
large enough to bind without cutting. 

Retaining Apparatus.—The author 
is in favor of depending upon his 
fingers, and those of assistants, rather 
than upon clamps and other retaining 
apparatus in abdominal work; but 
this is because his methods were ac¬ 
quired while many of the proficient 
clamps which facilitate these proced¬ 
ures were in the course of develop¬ 
ment, and which gave mechanical 
advantages which seemed attractive, 
but which were sometimes observed 
to be injurious. Rubber-covered 
clamps of various forms, if carefully 
used, allow one to work speedily. 
One may not make such accurate ad¬ 
justments or such regular insertion of 
sutures if he disposes of mechanical 
adjuncts, and yet in cases where he 
can work quite as quickly without 
them the balance of advantage is in 
favor of the gentler method. Tem¬ 
porary steadying sutures may some¬ 
times be employed in addition to the 
fingers in order to maintain a viscus 
in a certain position while operation 
is being performed, and these are 
liable to do less harm than steel 
instruments in the peritoneal cavity. 
The author has employed most of the 
mechanical devices described for facil¬ 
itating operative work upon the 
stomach and bowel, but has dropped 
most of them, excepting the Murphy 
button, in favor of simple methods of 
suturing, and the button is not used 


nearly as often now as it was a few 
years ago. 

Drainage tubes for the most part 
should be small, as otherwise they 
play the part of a foreign body in the 
abdominal cavity, and this is resented 
by the peritoneum. In 1895 the 
author described, in his book on the 
subject of appendicitis, a drainage 
wick which would take the place of 
drainage tubes in most places in the 
peritoneal cavity, and which would 
cause very little offense to the perito¬ 
neum. It consisted of gauze rolled 
loosely in a covering of gutta-percha 
or of rubber dam, very much as one 
rolls a cigarette, but leaving one end 
of gauze protruding. This soft, flexi¬ 
ble drainage wick acts by capillarity, 
adapts itself to bends and angles, and 
suffices for most purposes of abdom¬ 
inal drainage, provided that one 
understands the principles of capillary 
drainage, and keeps a good mass of 
fresh gauze upon the abdominal wall 
in such a way as to maintain the 
capillary power of the wick. 

Gauze drains not protected with an 
inoffensive covering are quickly filled 
with lymph-coagula poured out from 
the peritoneum in response to their 
irritating presence, and they become 
fastened to tissues in such a way that 
on removal they may draw loops of 
bowel into angulation. Where a very 
long drain is required, as from the 
cystic duct or from the bottom of the 
pelvis, the same principle may be ap¬ 
plied by using an ordinary flexible- 
rubber drainage tube or catheter split 
throughout its entire length on one 
side, and the wick of absorbent gauze 
carried loosely through the lumen of 
the tube. It is very seldom at the 
present time that one will need to use 
any gauze packing in the peritoneum 


8 


ABDOMEN, SURGERY OF (MORRIS). 


cavity; but if such a calamity does 
arise, less harm is done if the gauze 
is covered with an apron of gutta¬ 
percha tissue or rubber dam to keep 
the bowel from becoming adherent, 
thus carrying out in a way the prin¬ 
ciple of the protected drainage wick. 
For patients with very heavy abdom¬ 
inal walls where pressure might nearly 
close the wick drain with its cover of 
rubber dam, or of rubber tubing, sheet 
lead is a useful part of our apparatus. 
Sheet lead can be 'cut with the scis¬ 
sors into strips of any desired width 
or length, and this strip doubled upon 
itself carries between the two arms a 
drain of absorbent gauze. The end of 
lead projecting upon the external 
abdominal wall can be bent over to 
avoid the danger of the drain slipping 
within. Lead seems to be quite as 
benign as rubber or gutta-percha 
tissue, and is accepted kindly by the 
tissues, excepting where it projects 
to some distance within the abdom¬ 
inal cavity, in which latter case it 
presents a more rigid and objection¬ 
able foreign body. 

Sheet rubber is superior to gauze 
sponges in abdominal operations. It 
eliminates the danger of leaving a 
sponge in the abdomen as well as the 
local acapnia due to contact of the 
moist sponge and the resulting shock, 
a condition demonstrated by Hender¬ 
son. Rubber sponges also eliminate 
the tendency to form adhesions, so 
easily induced by the use of gauze. 
The wound itself heals more easily 
and the after symptoms of discom¬ 
fort are markedly decreased. Steril¬ 
izing of the sheet by boiling is easy. 
J. W. Keefe (Jour. Amer. Med. 
Assoc., Aug. 19, 1916). 

Suture Materials.—The choice of 
suture materials in abdominal surgery 
is extremely important. 

For ordinary ligating of vessels. 


and for suturing of the peritoneum 
where adhesions are to be avoided, 
very simply prepared catgut is pref¬ 
erable, and excepting for large vessels 
a catgut which would be absorbed in 
forty-eight hours possesses advan¬ 
tages, because any suture material for 
the peritoneum which remains for 
two or three days is prone to cause, 
by its irritating presence, a line of 
peritoneal lymph-exudate followed by 
annoying adhesions. This is in ac¬ 
cordance with the well-known action 
of the peritoneum in walling in any 
object which is a source of irrita¬ 
tion. While such adhesions may be 
absorbed later, and may not be in a 
position to cause much annoyance, 
nevertheless there are many thou¬ 
sands of patients today suffering to 
some degree from adhesions of the 
omentum or bowel to the anterior 
abdominal wall, in cases where this 
complication could have been entirely 
avoided by the use of very fine, 
quickly absorbed suture material, 
which would not have caused the 
pouring out of much lymph by 
the peritoneum. Peritoneal margins 
united with the finest of sutures 
become adherent so quickly that there 
is no real need for any suturing which 
will last for more than twenty-four 
hours in the parietal peritoneum of 
the abdominal wall, or in other places 
where strong permanent adhesions are 
not purposely induced. 

For suturing the cut margins of 
bowel or stomach for the purpose 
of preventing hemorrhage, and of 
closing of tissues against infection, 
small chromic catgut in the place of 
simply prepared catgut is desirable, 
for it resists digestion when in con¬ 
tact with the secreting glands of 
these organs longer than simply pre- 


ABDOMEN, SURGERY OF (MORRIS). 


9 


pared catgut. Simply prepared cat¬ 
gut, when in the secreting glands of 
the stomach or bowel, may be lique¬ 
fied in a very few hours, and chromic 
catgut in this position will do no 
harm, because it is at a point where 
adhesions are purposely secured. 

Linen thread and silk are used in 
the positions where we wish snug 
apposition of tissues until firm adhe¬ 
sions have been formed, or cut struc¬ 
tures of the stomach or bowel have 
united. For closing all parts of the 
abdominal wall we may dispose of 
any suture material, excepting the 
very fine, simply prepared catgut for 
the peritoneal layer and skin, and 
chromic catgut for the anterior and 
posterior sheaths of muscles; but, in 
place of chromic catgut where a last^ 
ing, yet absorbable material is desired, 
the author is very fond of kangaroo 
tendon. It is remarkably benign in 
the tissues, which receive it with 
such a degree of toleration that large 
strands are carried readily, and the 
kangaroo tendon lasts in the tissues 
for a longer time than chromic catgut, 
unless the latter is prepared in a way 
which makes it so 'hard as to be 
irritating. 

LOCAL ANESTHESIA.— The dangers 
attending general and even spinal anes¬ 
thesia in greatly weakened or moribund 
patients are being increasingly recognized, 
and corresponding attention is paid to 
local anesthetic methods. Lennander 
pointed out that, in general, anesthesia of 
the abdominal wall and parietal peri¬ 
toneum is alone necessary to permit of 
intra-abdominal surgery, and upon this 
basis the. indications of local anesthesia 
have been gradually extended in this field. 

No operation under general anes¬ 
thesia should be performed on an 
adult which can equally well be done 
under local anesthesia, in view of the 
greater safety of the local procedure. 


The writer blocks off the line of in¬ 
cision by completely surrounding the 
^ area with a barrier of 0.5 per cent, 
f novocaine (procaine) solution to 
>5 which 3 to 5 drops of 1: 1000 adren¬ 
alin solution per ounce have been 
added. The peritoneal cavity having 
• been entered, the patient makes no 
complaint, unless tugging and pulling 
on the viscera are indulged in. Local 
anesthesia is particularly indicated in 
the presence of alcoholism, nephritis, 
myocarditis, and acute myocarditis, 
but is also well suited for such op¬ 
erations as suprapubic cystostomy, 
gastrostomy, enterostomy, cholecys- 
tostomy in debilitated patients with 
gall-bladder empyema or severe ob¬ 
structive jaundice, appendectomy in 
tuberculous patients, all hernia opera¬ 
tions, and operations for typhoid per¬ 
foration. Vomiting seldom follows 
such anesthesia, and food can be 
taken shortly after the ^operation. 
J. H. Jacobson (Jour. Mich. State 
Med. Soc., XV, 57, 1916). 

The toxicity of novocaine is de¬ 
pendent upon the strength of solu¬ 
tion rather than upon the' total 
amount used and its coniparative 
safety makes possible the use of the 
drug in large quantities. Perfect 
anesthesia results in negative intra¬ 
abdominal pressure, producing post¬ 
mortemlike repose which permits vis¬ 
ual examination which is, of course, 
preferable to digital. The contra¬ 
indications to local anesthesia are 
largely limited to: (1) psychic 

incompatibility; (2) pathology adher¬ 
ent to the posterior parietal peri¬ 
toneum; (3) adherent malignant dis¬ 
ease; and (4) very high-lying gall¬ 
bladders. Abdominal packs are not 
needed except to prevent soiling, 
orientation being obtained by the 
negative intra-abdominal pressure, 
vertical retraction, etc. There is a 
very marked decrease in such post¬ 
operative discomforts as gas, nausea, 
and vomiting with the resultant 
wound strain. Children of all ages 
lend themselves well to the method. 
The time required is greatly reduced 
by use of the pneumatic injector, 2 to 


10 


ABDOMEN, SURGERY OF (MORRIS). 


5 minutes being all that is necessary 
with proper technique, after which 
the operation may be begun at once. 
If the anesthesia becomes inadequate, 
general anesthesia may be resorted 
to at any time. R. E. Farr (Journal- 
Lancet, xxxvii, 353, 1917). 

Exceptions to the rule that parietal 
anesthesia is alone necessary for abdom¬ 
inal operations are the lesser omentum, 
the cystic and common bile-ducts, the por¬ 
tal vessels, the renal capsules, and the 
ureters, all of which are sensitive (also the 
pelvic and diaphragmatic peritoneal sur¬ 
faces). 

Preliminary injections of morphine and 
scopolamine are very useful, and often 
practically indispensable in extensive op¬ 
erations under local anesthesia. 

Our associate editor, W. Wayne Bab¬ 
cock, recommends a 1 per cent, novocaine 
solution for the skin incision and a 0.25 
per cent, solution for the deeper tissues. 

In the splanchnic analgesia a wheal 
is raised 7 cm. from the midline at 
the lower border of the twelfth rib. 
A needle 12 cm. in length is passed 
through along the horizontal plane 
of the body, and introduced obliquely 
forward so that it makes an angle of 
about 45° with the median plane. 
When it strikes the vertebra, about 
9 cm. from the point of entrance, it 
is drawn back and then reintroduced 
at a smaller angle. As soon as the 
point is felt gliding along the surface 
of the vertebra it is pushed in 1 cm. 
further. At this point 25 to 35 c.c. 
of 1 per cent, novocaine-adrenalin 
solution are injected after it has been 
ascertained that no blood comes out 
of the needle. This procedure is then 
repeated on the other side. G. L. La- 
bat (Brit. Jour. Surg., viii, 278, 1921). 

POSTOPERATIVE TREAT¬ 
MENT. —The patient on being re¬ 
turned to bed should have wool next 
the skin and hot bottles at the ex¬ 
tremities, even though not much 
sihock be present, for shock is present 
to some degree after almost any 
abdominal operation, due to stimula¬ 
tion of the afferent nerves of the 


brain and cord centers, with more or 
less lack of vasomotor power. There 
is apt to be more or less perspiration 
from leaking sweat-glands when the 
patient is placed in bed, and any 
undue exposure at this time may lead 
to a chilling which would be inducive 
to postoperative pneumonia. For the 
first twenty-four hours approximately 
the disturbance of the intimate gang¬ 
lia of the bowel will usually result in 
'derangement of function of the bowel 
so that any food material is apt to 
undergo fermentation instead of diges¬ 
tion, and the toxemia from such fer¬ 
mentation may be very injurious, and 
might give rise to serious complica¬ 
tions. 

Thirst is inseparable from the post¬ 
operative period, and hot water given 
in teaspoonful doses frequently will 
partially allay the thirst, and supply 
all the real needs of the stomach 
for some hours after the operation. 
Patients are very urgent at times in 
their demands for cold water or ice 
after an operation, but cold water has 
a distinct tendency to increase vomit¬ 
ing, and ice in the mouth produces 
the same reaction that cold does upon 
the skin, as one observes after making 
snowballs: the hands become red and 
irritated, and in the same way the 
mucous membrane of the mouth and 
pharynx becomes irritated, if the 
patient is allowed ice or ice-water, 
excepting in the most minute quanti¬ 
ties. 

The injection of a quart of normal saline 
solution into the lower bowel immediately 
at the close of the operation and'while the 
patient is still under the influence of the 
anesthetic, has also been recommended 
for the relief of thirst. The patient is ele¬ 
vated to the moderately high Trendelen¬ 
burg posture, a stiff rectal tube inserted 
well up into the sigmoid flexure, and the 


ABDOMEN, SURGERY OF (MORRIS). 


11 


fluid slowly poured into a glass funnel, 
held 3 or 4 feet above the level of the but¬ 
tocks. John G. Clarke found that this 
procedure also reduced to a minimum the 
vesical irritability, so common in operative 
cases. Editors. 

Diet.—The first food to be borne 
after the hot-water period is passed 
is liquid diet and predigested milk, or 
fermented milk of several kinds, and 
broths are usually well borne. In 
two or three days, if the temperature 
and other vital signs are fairly normal, 
a more liberal diet will allow the 
patient to regain strength more 
rapidly. Meteorism, which is usually 
present to some extent, with or with¬ 
out colic, because of the disturbance 
of the sympathetic ganglia of the 
abdomen, may be relieved ordinarily 
if stimulating enemata are given; 
but for the most part it is well to 
leave the patients pretty much alone, 
without attempting to do too much 
for them during the first twenty-four 
hours after an abdominal operation. 
Many times the author has asked 
patients what they most desired dur¬ 
ing the first day after an abdominal 
operation, and the common answer 
has been that their greatest desire 
was to be left alone. 

Opiates.—There is a general ten¬ 
dency to give opium in some form 
after abdominal operations, if the 
patient is in pain, but we must 
remember the specific action of opium 
in lessening the resistance to the 
spread of infection immediately after 
an operation, and not apply mistaken 
efforts at kindness in wishing to quiet 
the patient’s pain. There are some 
patients of nervous temperament who 
suffer so much and who are so rest¬ 
less that they tire themselves out with 
fretting, if we do not give opium in 
some form. 


Consequently the resource is one 
that we may be obliged to use, but it 
should not be used excepting with 
full knowledge of its danger. It is 
the author’s habit to tell patients in 
advance of operation that they are 
going to suffer a great deal afterward 
from colic, nausea and pain, but that 
they will arrive at a comfortable 
stage soon afterward. The effect ofl 
this statement to the patient has 
never, so far as the author knows, 
deterred anyone from having an op¬ 
eration done, as there is the natural 
feeling of pride in being able to meet 
such conditions, and the patient, ex¬ 
pecting a good deal of trouble imme¬ 
diately after operation, and prepared 
for it, is frequently enough surprised 
to find it so mudi less in degree than 
had been anticipated. 

Where the patient recovers quickly 
from the anesthetic and vomits or be¬ 
comes restless, % grain (0.01 Gm.) of 
morphine sulphate may be given 
hypodermically. If he sleeps out of 
the ether, it is not necessary until 
later. Rectal saline, 1 pint (ShO c.c.) 
should be administered slowly before 
the patient recovers from the anes¬ 
thetic, or immediately after. Water, 
either hot or cold as best tolerated, 
is given as soon as the patient asks 
for it. H. W. Jones (N. Y. State 
Jour, of Med., xvii, 458, 1917). 

Insomnia is so dependent on stom¬ 
ach and bowel disturbances that the 
two belong closely in association. 
Insomnia which is dependent upon 
the disturbance following an opera¬ 
tion is not so distressing if the patient 
has a good nurse who suggests quiet 
in all of her movements, and who 
does not allow avoidable disturbances 
to keep the patient awake. Sleep will 
be established frequently in a natural 
way by the fhird night. Part of this 
insomnia at night is due to the fact 


12 


ABDOMEN, SURGERY OF (MORRIS). 


that patients doze off at various times 
during the day, and really get during 
the twenty-four hours’about all of the 
sleep that is necessary. A number of 
ordinary hypnotics, avoiding the opium 
preparations, will give some relief, 
and this is a matter which must be 
left to the judgment in individual 
cases rather than stated in the way 
of a general rule. 

POSTOPERATIVE COMPLICA¬ 
TIONS.—Shock when severe in de¬ 
gree requires special treatment in 
addition to the customary methods 
for retaining the body heat and keep¬ 
ing hot bottles at the extremities. 
Elevation of the foot of the bed 
temporarily allows the heart to work 
with less effort, but we have to be 
guarded about suddenly lowering the 
foot of the bed at any time while the 
patient is still in a condition of shock. 
The patient at this time may be suffer¬ 
ing from one of two kinds of anemia: 
anemia due to lack of vasomotor 
power and perhaps also anemia due to 
direct loss of blood. For the anemia 
due to loss of vasomotor power 
secondary to derangement of function 
caused by disturbance of the sympa¬ 
thetic ganglia of the abdomen strych¬ 
nine is indicated, and should be given 
hypodermically in doses of from a 
thirtieth to a twentieth at intervals 
of about four hours. 

For the anemia due to actual loss 
of blood the indications are for sup¬ 
plying the loss of blood temporarily, 
and this is done either by direct trans¬ 
fusion of blood or more commonly by 
intravenous infusion of normal saline 
solution. In cases in which we have 
both kinds of anemia present at the 
same time the use of the strychnine 
may be quickly transitory and injuri¬ 
ous, unless we have first by transfu-. 


sion or infusion given the heart and 
blood circulatory system the mechan¬ 
ical advantage of possessing a full 
complement of fluid. 

The use of saline solution by rec¬ 
tum is protested against by the 
writer, who found a transient al¬ 
buminuria to result from this pro¬ 
cedure in a large series of cases. 
Plain water should be given by rec¬ 
tum instead. Comparative tests 
showed that one-third more fluid is 
thus absorbed, and that less water is 
required by the mouth. Trout (Surg., 
Gynec. and Obstet., May, 1913). 

Basing their conclusions on 356 op¬ 
erated abdominal penetrating wounds, 
the writers consider camphor in oil 
the best cardiac stimulant; pituitrin 
intramuscularly in half-ampoule doses 
aids peristalsis and eserine is also 
often of value for this purpose. Two 
hundred Gms. (6% ounces) of saline 
solution, with or without 30 Gms (1 
ounce) of brandy, should be given by 
rectum every 3 hours as a routine in 
all cases and continued for 2 to 3 
days. Small sips of brandy or cham¬ 
pagne, or Yz Gm. (8 minims) of tinc¬ 
ture of iodine in 4 Gms. (1 fluidram) 
of water usually controls hiccoughs. 
Lockwood, Kennedy, Macfie and 
Charles (Brit. Med. Jour., Mar. 10, 
1917). 

Adrenalin or digitalis are powerful 
stimulants, but they stimulate the 
heart out of proportion, and are very 
transitory in effect, and unless given 
with great caution may lead to over- 
stimulation, especially if given in con¬ 
junction with strychnine. Overstimu¬ 
lation will be followed by secondary 
shock coming on a few hours after 
apparent recuperation from the first 
evidences of shock. Bandaging the 
legs firmly in order to drive out the 
blood in part and give the heart less 
work is, like elevation of the foot of 
the bed, a resource of temporary 
value, but we need to be guarded 
about removing the bandages before 


ABDOMEN, SURGERY OF (MORRIS). 


13 


recuperation from the condition of 
shock is well established. 

The best method of administering the 
suprarenal principle, according to A. J. 
Walton, is by continuous rectal injection 
in saline solution, 1 dram of adrenalin 
solution to a pint of saline, i.c., 1 in 160,- 
000; the temperature of the liquid should 
be between 108° and 112° F., and it should 
not flow in faster than 1 pint an hour. 
Crile found that by giving adrenalin con¬ 
tinuously, the circulation of a decapitated 
animal could be maintained ten and a half 
hours. 

Hypodermic injections are absorbed 
very slowly during severe shock, but in¬ 
travenous injections of adrenalin or of 
pituitary extract raise the blood-pressure 
more than in the normal state. A single 
injection of an extract of the posterior 
lobe of the pituitary was found by Mum¬ 
mery and Symes to influence arterial tone 
for upward of an hour. 

Six cases of gall-bladder and ap¬ 
pendix disease which, from 36 hours 
to 2 weeks after operation, though 
apparently convalescing nicely, de¬ 
veloped symptoms of acute myocar¬ 
ditis with dilatation of the heart. 
This is believed due to secondary in¬ 
fection, operation exciting strepto¬ 
cocci in the gall-bladder, they having 
a selective affinity for the heart 
muscle. A stock vaccine or antitoxin 
might be developed from the gall¬ 
bladder or other organ involved and 
used in each case. E. A. Vander 
Veer (Trans. Amer. Surg. Assoc., 
June, 1917). 

Meteorism of extreme degree also 
appears to depend upon two chief 
factors: partial paralysis of the mus- 
cularis of the alimentary tube due to 
disturbance of the sympathetic cen¬ 
ters, and to fermentation of contents 
of the alimentary tract caused by 
-saprophytes, which gain ascendancy 
when the normal control occurring in 
the course of undisturbed digestion is 
taken away. The meteorism second¬ 
ary to mechanical obstruction or of 


spreading peritonitis includes these 
same prime factors, but the different 
forms of this condition require treat¬ 
ment based upon causation in the indi¬ 
vidual case. The meteorism which is 
due to simple shock calls for mechani¬ 
cal treatment chiefly, although the 
fermentation of intestinal contents is 
relieved to some extent by the use of 
subgallate of bismuth as an intestinal 
antiseptic, and by the use of the lactic 
acid ferment, consisting of prepared 
cultures of the Bacillus Bulgaricus, 
which now may be obtained in tablet 
form, or which may be used indirectly 
in milk prepared by the action of this 
bacillus. 

Mechanical resources consist, in 
ordinary cases, of introducing a rectal 
tube to allow the early escape of gas, 
and by abdominal massage applied 
gently but persistently, beginning at 
the right side over the cecum and car¬ 
rying the massage along the entire 
course of the colon. This order of 
massage movements seems to relieve 
distention of the small bowel quite as 
well as the colon, probably because of 
the natural tendency toward emptying 
of the small bowel into the colon. In 
the presence of severe colic in meteor¬ 
ism, massage would seem to be contra- 
indicated, but it is not, because colic is 
due to a spasm of the muscularis of the 
bowel in its effort to contract to the 
normal caliber, and massage move¬ 
ments seem to give to the bowel the 
same sense of security that is obtained 
by a splint in cases of fractures at¬ 
tended with muscular spasm of the 
extremities. 

The author is impressed by the fact 
that treatment of meteorism of the 
bowel in this way by massage and by 
the rectal tube is not commonly appre¬ 
ciated as it should be, and he has very 


14 


ABDOMEN, SURGERY OF (MORRIS). 


many times afforded decided and last¬ 
ing relief by these resources. 

A hypodermic injection of V 50 grain 
(0.0013 Gm.) of eserine salicylate gives ex¬ 
cellent results, according to F. E. Taylor, 
in tympanites after colotomy. Within 
fifteen minutes the patient begins to pass 
flatus. An enema of sulphate of mag¬ 
nesium should then be administered. If 
necessary, the injection may be repeated 
in six hours. 

Acute dilatation of the stomach 

belongs to the same category, is prob¬ 
ably dependent upon the same causes 
as meteorism of the bowel, and has 
practically the same order of compli¬ 
cations. In many cases there seems 
to be selective impression made upon 
the innervation of the stomach by 
shock, perhaps because of its proxim¬ 
ity to the solar plexus, and dilatation 
of the stomach occurs out of propor¬ 
tion to dilatation of the bowel. When 
we recognize acute dilatation of the 
stomach by the persistent vomiting, 
distress, and visible distention of the 
upper left quadrant of the abdomen 
in excess of distention of other parts 
of the abdomen, we have the charac¬ 
teristic features of this form of 
meteorism. In this condition the 
mechanical features of treatment are 
all important, and are obtained by 
placing the patient prone upon the 
abdomen, with the result of causing 
constant compression of the distended 
stomach. With the patient in this 
position, the stomach tube introduced 
at frequent intervals, washing of the 
stomach with warm saline solution 
results in causing the escape of very 
large quantities of gas. Patients suf¬ 
fering from this condition are not 
so sensitive to the introduction of the 
stomach tube as many others, and 
the immediate relief which is given 
temporarily often makes them eager 


for the next introduction of the tube. 
The important matter is to apply the 
stomach tube often enough, and this 
is a point commonly neglected. We 
must keep the stomach empty of gas 
and fermenting contents. 

In cases in which the patient hap¬ 
pens to rebel against introduction of 
the stomach tube because of highly 
sensitive fauces we may spray the 
fauces in advance with cocaine solu¬ 
tion, and, if the tube is lubricated with 
a nice quality of sweet oil to which 
is added a few drops of wintergreen, 
the patient, relishing this, will chew 
the tube for a few moments, and then 
begin swallowing it. Further advance 
of the tube is made by the surgeon. 

Meteorism due to mechanical ob¬ 
struction of the bowel is also met 
with. At the present time we see very 
much less of dynamic and adynamic 
ileus than we did some years ago, 
when it was common practice to use 
gau?:e packing in abdominal surgery. 
This gauze packing lowered the 
patient’s general resistance, as a 
foreign body in the peritoneal cavity. 
It caused excessive exudation of 
plastic lymph from peritoneal sur¬ 
faces, and adhesion angulation was a 
frequent feature in consequence, or if 
not angulation, the arrest of peristalsis 
from the involvement of the long 
segments of the bowel among adhe¬ 
sions. 

That form of ileus in which per¬ 
istalsis progresses violently up to the 
point of arrest with a rapid produc¬ 
tion of grave symptoms can often¬ 
times be relieved by posture. If the 
patient’s hips and legs are elevated 
upon the back of a chair which has 
been placed upside down in bed, and 
gentle massage applied, gravitation 
will sometimes stop the angulation or 


ABDOMEN, SURGERY OF (MORRIS). 


15 


kinking of bowel in a few minutes, 
and it is gratifying to see the whole 
picture of a desperate case change so 
rapidly as it sometimes will when 
this posture resource is being applied, 
together with gentle massage. Re¬ 
opening of the abdomen and a search 
for the point of mechanical obstruc¬ 
tion are such very fatal procedures 
that they must not be employed with 
much hope of obtaining relief, but 
some authors hope, which the author 
does not share freely, to secure an 
occasional good result by opening the 
distended bowel by incising it after 
reopening the abdominal cavity to 
allow the escape of gas, or by inject¬ 
ing sulphate of magnesia solution 
through trocar punctures in the 
bowel. Clinically I think that we 
may usually observe that when the 
bowel is opened at any point for the 
escape of gas it allows the escape of 
gas only in the immediate vicinity, 
the paralysis of the bowel preventing 
the contraction necessary for empty¬ 
ing the lumen at more distant points. 
Rapid opening of the distended bowel 
at a point above the obstruction, inser¬ 
tion of a drain to carry off the poison¬ 
ous contents, and subsequent operation 
for the relief of the obstruction, after 
the patient has made some gain, is 
occasionally successful. 

Our resources must be applied 
promptly in cases of ileus with 
meteorism, because toxins generated 
in any part of the bowel which is not 
emptying itself rapidly lead to a 
dangerous toxemia, and the colon 
bacillus particularly increasing in 
virulent culture in an obstructed or 
paralyzed part of the bowel may not 
only cause general toxemia, but may 
be carried to the kidneys and liver, 
and there give origin to a train of 


serious complications discussed under 
the next heading. 

Thirteen cases of acute gastric dil¬ 
atation during operation. All but 1 
were relieved by prompt passage ot 
the stomach tube. All postoperative 
cases with more than the usual eme¬ 
sis should receive gastric lavage. 
When dilatation has developed, re¬ 
peated gastric lavage must be carried 
out. In extreme cases the patient 
should be placed in the knee-chest 
position to facilitate complete evacua¬ 
tion. E. Novak (Jour. Amer. Med. 
Assoc.., Ixxvii, 81, 1921). 

Colon Bacillus Nephritis.—If this 
continues after relief from the ileus 
has been obtained, it will require 
special treatment internally. Five 
grains of benzoate of soda combined 
with five grains of hexamethylenamine 
administered at rather frequent inter¬ 
vals, according to the judgment of the 
physician, will exert a specific influence 
Upon the complication of colon bacil¬ 
lus nephritis which so commonly 
follows conditions that entail loss of 
control over this bacterium. When the 
benzoate of soda and hexamethylena- 
min internally do not control colon 
bacillus nephritis in a satisfactory way, 
the pelvis of the kidneys may be 
flushed through a ureteral catheter. 

In many cases one may state inci¬ 
dentally that colon bacillus nephritis is 
often enough present in advance of 
operation in many abdominal condi¬ 
tions, passing for ordinary nephritis, 
unless one devises means for de¬ 
termining if the colon bacillus is 
present, and the author has known of 
instances in which excellent consult¬ 
ants wished to postpone operation 
because of the presence of albumin¬ 
uria, when, as a matter of fact, this 
albuminuria was due to the presence 
of the colon bacillus, and to be cured 
only after removal of the focus of 


16 


ABDOMEN, SURGERY OF (MORRIS). 


original infection by the abdominal 
operation. The colon bacillus nephri¬ 
tis which occurs with appendicitis 
may often clear up rapidly after the 
operation without any special treat¬ 
ment directed to the nephritis, and 
the same result may be anticipated in 
a certain proportion of the cases of 
colon bacillus nephritis occurring 
with ileus. 

Meteorism due to extension of 
peritonitis after operation is some¬ 
times treated by the old Clark opium 
method, which consists in placing the 
patient profoundly under the influ¬ 
ence of morphine. It acts by limiting 
the spread of peritonitis due to peris¬ 
taltic movements of the bowel, and 
the loss of resistance on the part of 
the patient from the shock which 
goes with peritoneal pain. On the 
other hand, we have the objection that 
bacteria increase more rapidly in a 
patient under the influence of opium. 
In addition to the beneficial influence 
of opium in selected cases, the ice-coil 
placed on the abdomen has the tend¬ 
ency to lessen the spread of peritonitis 
besides limiting the pain. 

The author has preferred the prin¬ 
ciple of turning the blood-current 
toward emunctories of the bowel, and 
securing elimination of toxins along 
with a free watery discharge from the 
mucosa of the bowel. This is accom¬ 
plished fairly well by the high rectal 
injection of an ounce of alum in a 
quart of water. The alum in the bowel 
produces the same effect that it does 
in the mouth, causes rapid watery 
secretion from neighboring glands, 
and incidentally stimulates contrac¬ 
tion of the paralyzed bowel, with 
emptying of its contents. We might 
anticipate that alum would have in 
the bowel an, astringent effect, with 


the tendency to cause constipation, 
but it has precisely the reverse action, 
and the great amount of watery 
exudate which is drawn out in the 
presence of alum seems to overcome 
any irritating effect which it might 
have. 

Sulphate of magnesia by high injec¬ 
tion has an effect like alum, of causing 
watery evacuation which presumably 
carries off toxins, and the influence of 
sulphate of magnesia is probably due 
to its hygroscopic nature, drawing 
fluids from the peritoneal cavity 
toward the bowel lumen by osmosis. 
The sulphate of magnesia injection, 
either alone or combined with gly¬ 
cerin, which is also hygroscopic, is 
perhaps the favored method of obtain¬ 
ing movement when there is any 
degree of paralysis of the bowel, but 
the alum injection is much more 
effective, and will act in cases where 
paralysis is established to such a 
degree that sulphate of magnesia 
would exert no apparent influence. 
In addition to these rectal injections, 
a very gentle massage is effective in 
some cases in overcoming the par¬ 
alysis of the bowel, although it seem¬ 
ingly would be contraindicated. In 
cases where septic peritonitis is 
present at the time of operation, and 
there is danger of such peritonitis 
remaining as a postoperative compli¬ 
cation, the Murphy proctoclysis is 
invaluable. This consists of the very 
slow instillation of warm saline solu¬ 
tion into the rectum continuously for 
a long period of time, and many forms 
of special apparatus for the purpose 
have been devised. The apparatus of 
Dr. Robert C. Kemp maintains an even 
temperature of the saline solution by 
the use of the vacuum principle in the 
container of the fluid, similar to that 


ABDOMEN, SURGERY OF (MORRIS). 


17 


obtained by the thermos bottle. The 
methods here described for treating; 
cases with spreading peritonitis assume 
that we have made provision for suffi¬ 
cient drainage and have applied other 
resources in an operative way. 

As laxative enemas to be used, 
when necessary, after abdominal op¬ 
erations, the author mentions the 
following: (1) Magnesium sulphate, 
2 ounces (60 Gm.), in water at 102° 
F. (38.3° C.), 1 pint (500 c.c.). (2) 

Glycerin, 2 ounces, in water at 102°' 
F., 1 pint. (3) Castor oil, 2 ounces, 
in acacia emulsion (^ ounce—15 Gm. 
—of acacia to the pint of water). (4) 
Oxgall, 20 grains (1.3 Gm.), and 
glycerin, 1 ounce (30 c.c.), in starch- 
water, 1 pint (500 C.C.). Winslow 
Anderson (Pac. Med. Jour. Sept., 
1916). 

In postoperative ileus and intestinal 
paresis, the writer uses an enema of 
1 dram (4 c.c.) of stronger ammonia- 
water in 1 pint of water, the effect of 
which is greatly enhanced by a hypo¬ 
dermic injection of pituitrin, 16 
minims (1 c.c.), half an hour pre¬ 
viously. T. A. Black (Med. Rec., 
Apr. 1, 1916). 

Poisoning by bichloride of mercury 
and by iodoform have in the past 
been common postoperative compli¬ 
cations, although at the present time 
they do not occur so frequently, but 
still require attention. Poisoning by 
bichloride of mercury through absorp¬ 
tion from large wound surfaces gives 
rise to the characteristic irritation of 
the mucosa of the alimentary tract, 
but seldom appears in abdominal 
work, because there is almost no 
situation in which an expert operator 
would think of using bichloride of 
mercury. Iodoform, however, is very 
frequently used in abdominal sur¬ 
gery, but chiefly with iodoform gauze, 
and this gives rise to iodoform poison¬ 


ing so frequently that the author on 
one occasion, when being asked to 
look for it in a hospital ward, found 
several cases unsuspected in one 
ward. Iodoform is taken up very 
rapidly by the peritoneum, and its 
symptoms are commonly mistaken for 
the symptoms of septicemia, with 
rapid pulse, wet skin, and peculiar 
mental wandering. 

Where we have occasion to sus¬ 
pect that iodoform poisoning is a 
postoperative complication in abdom¬ 
inal work, we may determine the 
point by adding a pinch of calomel to 
some of the patient’s urine in a 
saucer, and stirring with a wooden 
spatula. If free iodine is present in 
the urine it makes the customary re¬ 
action to iodide of mercury, distin¬ 
guished at once by the cloud of color. 
Removal of iodoform gauze from the 
wound in such a case, and taking up 
iodoform which is adherent to the tis¬ 
sues by pouring sterilized oil into the 
cavity from which the gauze was re¬ 
moved, and leaving the oil there for 
some minutes before abstracting it 
with absorbent apparatus, will com¬ 
monly allow the patient to recover 
from a severe case of iodoform 
poisoning. 

Patients vary greatly in their sus¬ 
ceptibility to iodoform, and the author 
observed one death from iodoform 
poisoning with characteristic signs in 
a young girl, sixteen years of age, 
in a case in which he arrived too 
late in consultation. And the young 
girl had been poisoned by a roll 
of iodoform gauze, not much larger 
than two fingers in size, after an 
appendix operation. The surgeon in 
charge had been absolutely at a loss 
to account for the symptoms. While 
there are positions in which iodoform 


18 


ABDOMEN, SURGERY OF (MORRIS). 


gauze is of considerable value in 
small quantities in abdominal work, 
we must always bear in mind the 
danger of the. postoperative compli¬ 
cation of iodoform poisoning. 

Skin eruptions seen frequently after ab¬ 
dominal operations, were found by F. J. 
Shepherd to occur most often in patients 
receiving an enema of soapsuds made 
from common yellow soap. When Castile 
soap was substituted no eruption followed. 
Cheap, yellow soap contains a considerable 
quantity of resin, and to this he ascribes 
many of the rashes seen after abdominal 
section. 

Uncontrollable vomiting imme¬ 
diately following operation is prob¬ 
ably due to excessive stimulation of 
the nerves of the stomach through 
shock, or from the irritation of ether 
which is being excreted by the glands 
of the stomach, and it seems to be 
due also at times to reversed peris¬ 
talsis of the upper part of the bowel, 
throwing contents of the duodenum 
into the stomach, with continuance 
of the wave of reversed peristalsis to 
the point of including the entire stom¬ 
ach. This complication sometimes be¬ 
comes so dangerous that we must stop 
it by the chief means at our control, 
giving the patient the harmful mor¬ 
phine. 

If vomiting persists after 12 hours, 
the author gives 1 dram (4 Gm.) of 
sodium bicarbonate in 6 ounces (180 
c.c.) of lukewarm water. This washes 
out the stomach and usually results 
in cessation of vomiting. Rarely does 
it become necessary to resort to the 
stomach tube. In any case, sodium 
bicarbonate in doses of 20 grains 
(1.3 Gm.) every 3 hours is helpful 
for the first 2 or 3 days. It not only 
overcomes the acidosis, but appears 
to have a favorable influence on gas 
pain. H. W. Jones (N. Y. State Jour, 
of Med., xvii, 458, 1917). 


Properitoneal hernia is sometimes 
the cause for ileus with its vomiting 
and other train of symptoms, but it 
is not likely to occur in cases in which 
the operator is aware of the danger of 
this complication, and has guarded 
against it. Properitoneal hernia oc¬ 
curs in cases in which there has been 
defective suturing of the peritoneal 
layer of the abdominal wall after 
operation, and a small knuckle of 
bowel is forced by vomiting or cough 
into the space between the peritoneum 
and the muscular layer of the ab¬ 
dominal wall. 

Hernia into a rent in the omentum 
may occur as a postoperative compli¬ 
cation, and, if, in the course of separat¬ 
ing adhesions, the operator has left any 
small openings in the omentum, these 
should be extended clear to the 
margin of the omentum, or closed by 
suture. In any event, possibility of 
hernia complication should be foreseen 
in all work which deals with the omen¬ 
tum, if rents are left unclosed. 

Perforation of the bowel some¬ 
times occurs as a postoperative com¬ 
plication at the site where a rigid 
drainage tube or bulky drainage ap¬ 
paratus has caused an undue amount 
of pressure, and perforative ulcer may 
occur a few days after the operation 
at the site of a gastroenterostomy, if 
the bowel has been fastened so far 
away from the pylorus that acid con¬ 
tents of the stomach escape directly 
into the bowel at the point of junc¬ 
ture. 

Postoperative phlebitis occurs often 
enough to require attention. It may 
appear two weeks after an aseptic 
operation, and its origin is not well 
understood. As a postoperative com¬ 
plication in appendicitis, it sometimes 


ABDOMEN, SURGERY OF (MORRIS). 


19 


appears as an inflammation of the left 
iliac vein or left saphenous vein, and 
occurs in fact at a distance quite as 
often as at the site of operation. 
While causing a high degree of dis¬ 
comfort and prolonging the period of 
illness, it is not often an absolutely 
dangerous complication. If abscesses 
are formed, they are apt to remain 
localized rather than to give rise to 
septic embolism. 

Pylephlebitis does not often occur 
as a postoperative complication, ex¬ 
cepting in cases in which we have 
evidences of its presence in advance 
of operation, but abscess- of the liver 
may appear so late after an abdominal 
operation that the relationship be¬ 
tween the primary focus of infection 
in the peritonal cavity and the liver 
abscess may be lost sight of. A 
patient may even leave the hospital, 
and his home, and travel to a dis¬ 
tance for recuperation, with beginning 
abscess of the liver, the treatment 
for which will receive consideration 
under the heading of that subject. 

Secondary abscess may appear at 
the site of an infection which has 
been cared for at the time of opera¬ 
tion, but such secondary abscess is 
prone to liquefy newly coagulated 
lymph toward the external abdominal 
incision, and to follow this line of 
least resistance, rather than to extend 
in other directions. 

Mesenteric thrombosis not mark¬ 
edly present at the time of an opera¬ 
tion may increase to become a post¬ 
operative menace, due probably to 
injury of the veins in the course of 
an operation, but the complication is 
rare. 

Bladder complications do not call 
for special consideration in this arti¬ 
cle. The bladder sometimes refuses 


to contract in a normal way after 
various abdominal operations. This 
is sometimes due to nothing more 
serious than the unaccustomed re¬ 
cumbent position of the patient, or 
to psychic influence, although shock 
sometimes leads to disturbance of the 
innervation of the bladder, and at the 
same time we are apt to have hypose- 
cretion of urine due to a similar influ¬ 
ence upon the kidneys. It is best to 
avoid using a catheter if possible for 
emptying the blatlder, and it is seldom 
necessary, excepting when we have di¬ 
rect evidence of an overfull bladder. 
Otherwise it is best to resort to such 
resources as massage of the bladder 
above the pubes, and the sound of 
trickling water upon a warm bed- 
pan placed beneath the patient. If we 
begin too early to use the catheter, 
there is a tendenc}) for the bladder to 
depend upon that resource for some 
days, and sometimes for as long as the 
patient remains in bed, if we begin with 
the mistaken idea that prompt use of 
the catheter will simplify matters. 

Postoperative psychoses occasion¬ 
ally occur after abdominal operations, 
and the operation is commonly held 
by relatives of the patient to be the 
primary cause. Such disturbances 
usually mean the precipitation of 
impending psychoses which were de¬ 
veloping in advance of the operation, 
but kept in check by the will of the 
patient until the shock and surround¬ 
ings of the operation relaxed that 
control. Such psychoses may be due 
to central causes, but are. also some¬ 
times toxic in origin, as the- abdom¬ 
inal surgeon sees them, and such 
psychoses precipitated by operation 
may be really on the road to elimina¬ 
tion, due to removal of the origin of 
the toxic impression. 


20 


ABDOMEN, SURGERY OF (MORRIS). 


Peritoneal adhesions causing trou¬ 
ble subsequent to operation receive 
consideration along with that general 
subject elsewhere in the article. 

Postoperative pneumonia occurs, 
according to various authors who 
have tabulated many thousands of 
cases, in from 2 to 5 per cent, of all 
abdominal operations, although in 
practice one may have series of one 
or two hundred operations without a 
single case of pneumonia, and it is 
very much less frequent today as the 
result of our refinement in technique 
than it was ten years ago. True 
croupous or lobar pneumonia, lobular 
pneumonia and hypostatic pneumonia 
may all stand in direct relationship 
to causes which are more or less 
under control by the surgeon. The 
development of true lobar pneumonia, 
developing immediately after an 
operation, seems to the author to be 
more than a coincidence. The dis¬ 
turbance incident to any abdominal 
operation may lower the vitality of 
the patient in such a way that the 
omnipresent pneumococcus may sud¬ 
denly spring into activity, particu¬ 
larly if ether has been the anesthetic. 
We have recent knowledge that in¬ 
fections of various sorts may begin 
quickly in animals under the influence 
of that anesthetic. The shorter the 
period of anesthesia, and of operative 
procedure which lessens general re¬ 
sistance, the less we shall probably 
have of true lobar pneumonia, which 
has generally been held to be merely 
coincidental. 

Hypo*static pneumonia after abdom¬ 
inal operations may appear for the 
same reasons that it appears else¬ 
where, but neither hypostatic nor 
true lobar pneumonia are so distinctly 
traced as postoperative complications 


.as is lobular pneumonia, and this 
lobular pneumonia is the particular 
one with which we usually have to 
deal. According to statistics, lobular 
pneumonia occurs more often after 
abdominal operations on the aged, 
and more often in men than in 
women, but the latter feature of the 
statistics does not have special refer¬ 
ence to abdominal operations. While 
general anesthetics are all more or 
less irritating to the bronchial 
mucosa, and postoperative vomiting 
is a factor allowing aspiration of 
mucus or substances from the stom¬ 
ach, there are other features leading 
to a special preponderance of lobular 
pneumonia after laparotomy. The 
pain following abdominal operations 
interferes with full range of the 
muscles of respiration and favors pul¬ 
monary stasis, but direct infection of 
the lungs by bacteria may occur in 
three ways: by way of the mucous 
membrane, the blood- and lymph- 
vessels. After abdominal operations, 
with a tendency to pulmonary stasis 
because of limited respiration on 
account of abdominal pain, and reten¬ 
tion of matters which would be ex¬ 
pectorated if coughing were not so 
painful, bacteria arriving at the lungs 
from the abdominal region by way of 
the blood- and lymph- vessels meet 
with resistance which is less than 
normal. The author believes that 
long exposure of the peritoneum in 
the course of an ordinary operation 
may lead to the carrying of large 
numbers of air bacteria indirectly to 
the lungs without complete destruc¬ 
tion en route by phagocytes, and it is 
his impression that these cases are 
not infrequent. Embolic pneumonia 
and its common sequence of lung 
abscess by infection through the 


ABDOMEN, SURGERY OF (MORRIS). 


21 


blood-stream no doubt occurs from 
the handling of thrombosed vessels, 
and, while we recognize certain cases 
of pneumonia directly due to the 
presence of the larger emboli, it is 
probable that we have many other 
cases in which minute emboli give 
rise to complications which appear a 
few days after operation. 

Pleurisy frequently follows opera¬ 
tions upon the liver and gall-bladder, 
if these operations are for cases with 
infection. Here it is probable that 
infection is transmitted by way of the 
lymphatics through the diaphragm 
to the pleura, and the neighboring 
lung becomes next infected, giving 
us sometimes the dangerous pleural 
pneumonia. The postoperative com¬ 
plication of pleurisy or of pleural 
pneumonia cannot well be guarded 
against, but we may anticipate the 
danger of postoperative lobular pneu¬ 
monia, and lessen this complication 
very distinctly in several ways: by 
avoiding as far as possible unneces¬ 
sarily prolonged operations with the 
accompanying long period of anes¬ 
thesia ; by maintaining the body 
warmth of the patient, and by allow¬ 
ing the patient postures which favor 
expectoration. It is probable that 
the Fowler position after operation, 
while not particularly favoring ex¬ 
pectoration, may lessen the danger 
from embolic pneumonia to some 
extent. 

Fistulas from the alimentary tract 
and bile-tract are sometimes annoy¬ 
ing as postoperative complications, 
but when not formed purposely for 
useful purposes they have a remark¬ 
able tendency to close spontaneously 
if left alone. Very much harm is 
done almost as a matter of routine at 
the present moment by surgeons. 


house staff assistants and nurses in 
their efforts at keeping such fistulic 
carefully cleansed. Antiseptics intro¬ 
duced into such fistulee cause disturb¬ 
ance of the delicate new cells which 
are being thrown out for purposes of 
repair, and even so harmless a solu¬ 
tion as saline solution is commonly 
injurious in fistulae. Employment of 
hydrogen dioxide, which cleanses 
fistulae in a most attractive way, is 
one of the most injurious of resources, 
because it destroys new cells quite as 
readily as it destroys pus. In cases 
in which we have reason to suspect 
that a fistula is kept open by some¬ 
thing at the bottom of the fistula, as 
a knot of unabsorbed ligature, a con¬ 
cretion, a bit of fecal matter, or other 
foreign body, we shall usually need 
to operate, for efforts at closing such 
fistulie are usually very futile until 
the foreign body is out. 

Excepting in cases in which we 
believe that a foreign body lies at the 
bottom of the fistula, our treatment 
had best be a treatment of neglect, 
doing nothing whatsoever in the way 
of cleansing the fistula, and simply 
using an external dressing for the 
purpose of cleanliness. Under this 
treatment new repair cells quickly 
form connective tissue, and such con¬ 
nective tissue, according to its well- 
known habit, contracts regularly and 
closes fistulae. There are a few cases 
in which epithelium will move down¬ 
ward from the skin and upward from 
the bowel, forming an epithelial 
covering for the walls of a short fistula, 
and when such short fistulae are seen 
to have an epithelial lining this may 
be destroyed by leaving 95 per cent, 
carbolic acid along the line of the 
fistula for half a minute, and then 
neutralizing it with alcohol. After 


22 


ABDOMEN, SURGERY OF (MORRIS). 


the destruction of epithelium in this 
way by carbolic acid, new cells are 
formed, but we must be sure that 
epithelial cells do not again cover the 
surface, and to guard against this the 
highly astringent subsulphate of iron 
is eflfective as an astringent which 
will not allow new epithelial cells to 
grow, but which does not prevent 
the development of connective-tissue 
cells, although connective tissue 
formation in such cases is tedious. 

One of the most persistent fistulae 
in the author’s practice followed an 
operation for perforating ulcer of the 
duodenum, in a patient whose large 
size and desperate condition did not 
allow detailed work at the ulcer site 
at the time of operation. This fistula 
discharged pancreatic secretion, bile 
and chyme for some months, but 
finally closed spontaneously. As a 
rule, it is best to allow the patient 
with a postoperative fistula to get out 
of bed as soon as the wound is 
secured in the ordinary way, and the 
patient then goes about his ordinary 
occupation and engages in all sorts 
of activities, with no attention to the 
fistula beyond the wearing of a small 
external pad of gauze for the purpose 
of neatness. 

Objects left behind after abdominal 
operations have led to complications 
in imposing array among statistics, 
and the gauze pad has been the chief 
offender. 

The foreign body may cause, according 
to Schachner, an acute or a low and pro¬ 
tracted form of sepsis; be encapsulated 
and retained for months or years; be ex¬ 
truded through the wound, or into the 
hollow viscera; or, more rarely, through 
the cicatrix. 

Proper organization of the operat¬ 
ing room prevents mishaps. Abso¬ 
lute quiet is essential, with well 


trained assistants each assigned to a 
particular task. Each instrument and 
piece of gauze should be accounted 
for. Some surgeons are apt to plead 
extenuating circumstances, but this 
occurrence occasions great suffer¬ 
ing and a probable lawsuit. Nature 
tends to protect itself from the for¬ 
eign body, and it may pass off 
through the rectum, but often a 
secondary operation is necessary. J. 
B. Deaver (Trans. Amer. Med. 
Assoc.; Med. Rec., Aug. 10, 1918). 

When one or more objects have been 
left behind in the peritoneal cavity 
the patient may go on to recovery, but 
usually there is a persistent nausea 
and a higher degree of local tender¬ 
ness and discomfort than we can 
usually account for, and the persist¬ 
ence of such condition of nausea and 
distress at the site of an operation 
may lead one to feel that it is best to 
reopen the abdominal cavity and 
search for a foreign body which has 
been left behind. This postoperative 
complication is not so easily guarded 
against as one might imagine; but 
gauze for intra-abdominal work, to 
which tapes have been attached, in 
the form of a long roll, one end of 
which is always left outside of the 
abdomen to guard against accident, 
should be employed. 

The danger of leaving sponges is 
eliminated by the author by dispens¬ 
ing with sponges and using a single 
band of sheet rubber 8 inches wide 
and 18 feet long. J. W. Keefe (Med. 
Rec., July 8, 1916). 

Secondary hemorrhage as a post¬ 
operative complication occurs more 
often in abdominal surgery than else¬ 
where, because of violent vomiting, 
which dislodges sutures and liga¬ 
tures. This must always be borne in 
mind, and we avoid the accident by 
introducing as few mass ligatures as 


ABDOMEN, SURGERY OF (MORRIS). 


23 


possible, and ligating vessels sep¬ 
arately. Very many cases of second¬ 
ary hemorrhage have occurred after 
ligation of the broad mesentery of 
the appendix, or of a broad ligament, 
because contraction of the psoas and 
iliac muscles, in addition to the other 
muscular contractions in vomiting, 
has a tendency to broaden out the 
peritoneal base and force ofif such 
ligatures, unless they have been tied 
with caution. Secondary hemorrhage 
occurs also when violent vomiting has 
caused fine sutures of silk or thread to 
cut out under tension, and for this rea¬ 
son the author favors sutures of larger 
caliber than are commonly employed. 
Where large vessels have been 
opened, and secondary hemorrhage 
occurs marked by the ordinary signs 
of increasing thirst, restlessness, 
pallor, pain and rapid pulse, we must 
reopen the abdominal cavity for 
securing bleeding points and remov¬ 
ing blood, and this is usually a very 
dangerous procedure because of the 
condition of the patient, requiring 
preparation for direct infusion of 
blood or introduction of intravenous 
saline solution at the moment the 
abdomen is reopened. Another form 
of secondary hemorrhage occurring 
after operation is common when the 
force of the arterial pulse is sufficient 
to give vis a tergo to blood in veins 
tom in separating adhesions, and 
which are not bleeding much at the 
time when the operation is completed. 

After any aseptic abdominal opera¬ 
tion considerable blood may escape 
into the peritoneal cavity without 
causing a great degree of disturbance 
beyond the increase in local pain, 
which is the characteristic sign of 
such hemorrhage. Aseptic blood in 
the peritoneal cavity is still in the cir¬ 


culation in a way, because the peri¬ 
toneal cavity is a lymph-chamber, and 
the serous remains of the blood which 
escape in the course of coagulation are 
taken up into the blood circulation 
again. Morphine lessens the hemor¬ 
rhage and strychnine increases it. 
Bearing these facts in mind, we may 
sometimes give the dangerous mor¬ 
phine to advantage, or withhold the 
strychnine unless it is greatly required. 

There are 3 chief explanations for 
failure of relief of symptoms after 
operation: 

1. The cause of the original symp¬ 
toms was extra-abdominal and opera¬ 
tive treatment was a therapeutic mis¬ 
take. In this group frequent causes 
of error are pneumonia on the right 
side associated with pleurisy which, 
because of referred pain in the abdo¬ 
men, is diagnosed as appendicitis, and 
pulmonary tuberculosis with gastric 
symptoms simulating gastric ulcer. 

2. An intra-abdominal lesion giving 
symptoms was present, but was not 
recognized by the operator and the 
wrong operation was done. In this 
group careful exploration of the ab¬ 
domen may show that gastric symp¬ 
toms were due to an encapsulated 
pelvic abscess or an old ectopic preg¬ 
nancy, that ureteral colic was the 
cause of appendiceal symptoms, or 
that a case thought to be a fibroid 
uterus was not helped by removal of 
fibroids because the real trouble was 
a carcinoma of the splenic flexure. 

3. The operation was a technical 
failure because it either failed to do 
what was intended, added new patho¬ 
logical conditions which caused a 
continuation of the old symptoms, or 
created new symptoms. In this group 
are mentioned removal of epiploic 
appendices for the vermiform appen¬ 
dix, partial removal of the appendix 
leaving an infected stump, gall-bladder 
surgery in which a stone low in the 
common duct is overlooked, opera¬ 
tions for visceroptosis failing to give 
the desired result. W. Wayne Bab¬ 
cock (Med. Rec. c, 319, 1921). 


24 


ABDOMEN, SURGERY OF (MORRIS). 


TOILET OF THE PERITO¬ 
NEUM. —The peritoneum protects 
itself so well, if given opportunity, 
that we need pay very little atten¬ 
tion to securing asepsis of any part 
of the abdominal cavity while we 
are at work. If pus escapes upon 
normal peritoneum when abscesses 
are opened, it commonly causes no 
harm, even though it be left upon the 
peritoneum when we are through 
with the operation. There are two 
reasons for this. Bacteria are chiefly 
at work in the tissues rather than in 
the pus proper, and the latter is often 
practically sterile, even in the presence 
of advancing infection. By pus I do 
not mean intraperitoneal fluids teem¬ 
ing with bacteria, but these are for 
the most part not walled in like pus. 
The principle, however, of treatment 
is practically the same; for where 
such fluids occur any special effort at 
securing asepsis would be futile, 
and, more than that, likely to be 
harmful. 

We may quickly arrange drainage 
for such septic fluids, but efforts at 
wiping or washing them out are apt 
to lead to injury of the endothelial 
covering of the peritoneum, and to 
defeat the object of our good inten¬ 
tions. 

When fluids carrying bacteria or 
sterile pus in quantity should be re¬ 
moved, it is best to do it very gently 
by quick absorption into masses of 
absorbent gauze, rather than by 
sponging or flushing, and we take 
good care at the same time to avoid 
the wiping which injures endothe¬ 
lium. Where stomach or bowel con¬ 
tents are likely to escape in the 
course of an operation, it is well to 
protect the field with absorbent 
gauze, but such gauze adheres quickly 


and firmly to normal peritoneum, with 
injury to its endothelium. Where we 
can apply the resource of placing a 
layer of rubber dam between perito¬ 
neum and gauze while we are at work, 
we guard the peritoneum in the best 
way. The peritoneum, while pro¬ 
tecting itself remarkably against in¬ 
fective material, is disabled by the 
washing and wiping commonly em¬ 
ployed, and particularly by the appli¬ 
cation of germicides, almost any one 
of which in the peritoneal cavity is 
productive of damage. 

A peritoneum which would be per¬ 
fectly safe, even though considerable 
septic fluid were left upon it, may 
when disabled start out on a career 
of infection which would have been 
avoided if we had not tried in a crude 
way to make the peritoneum ideally 
clean. In the vicinity of the focus of 
infection within the peritoneal cavity 
a local hyperleucocytosis becomes 
established with extreme rapidity, 
and this does away with the necessity 
for much of the work in toilet of the 
peritoneum described by authors in 
general. 

There are occasions in which it. is 
desirable to evacuate very large 
quantities of pus or septic fluids 
quickly, and for this purpose hydro¬ 
gen dioxide may be used, provided 
that all exits are kept free, and that 
the only peritoneum with which it 
comes in contact is peritoneum al¬ 
ready damaged. Hydrogen dioxide 
damages normal peritoneum instan¬ 
taneously, and is to be used only 
where the peritoneum has already suf¬ 
fered great damage, but in such situa¬ 
tions it throws out pus and septic fluids 
in a great foaming mass, and, this 
mass removed, saline solution may 
follow, leaving the cavity very clean. 


ABDOMEN, SURGERY OF (MORRIS). 


While hydrogen dioxide is germicidal, 
its value rests in its mechanical effect 
in throwing out albuminous fluids and 
debris rapidly, rather than in securing 
asepsis where it is not needed, and 
when efforts to secure it through the 
use of germicides are damaging. 
For most cleansing purposes in the 
peritoneal cavity physiologic salt 
solution is the best, although even 
that is to be used with caution. If it 
is not' employed with too much force 
or removed too vigorously it has a 
field of value. The solution of nine- 
tenths of 1 per cent., isotonic for 
human blood-serum, is more benign 
than the commonly employed six- 
tenths of 1 per cent, which is isotonic 
for frogs’ blood, and which had its 
origin in the laboratories. The saline 
solution should be sterilized by boiling. 

Sterile water, even though boiled, 
should never be used within the 
peritoneal cavity unless it contains 
salt. The reason why water without 
salt should not be used is because it 
is corrosive. Its corrosive nature 
may be noted at once by dropping it 
in the eye, which leads to immediate 
smarting and burning of the conjunc¬ 
tiva. Water without salt is so 
destructive to delicate tissues in 
laboratory work, and the fact is so 
well known, that it is a strange omis¬ 
sion on the part of many authors to 
neglect to state the dangerous char¬ 
acter of water without salt. 

The reason why even sterile pure 
water is corrosive is because an 
osmosis of salts from the body cells 
immediately occurs in the presence 
of water not containing those salts 
in the proportion in which they are 
found in the body cells. Chloride 
of sodium, however, being the chief 
salt involved, is the only one which 


25 

we need to add to the water for prac¬ 
tical purposes in routine work. 

Dawbarn poured milk representing 
septic fluid into the peritoneal cavity 
of a cadaver, and then set to work 
to find the best way to get all of 
the milk out again, and after a 
very great deal of flushing and spong¬ 
ing found that some milk still re¬ 
mained. 

This showed how impossible it is 
to remove the septic fluid by any 
mechanical toilet of the peritoneum, 
and demonstrates the degree of 
damage to peritoneum which will 
occur incidentally through our efforts. 
Consequently the toilet of the peri¬ 
toneum is best left in part to the 
peritoneum itself, aided by such 
resources as we have learned do not' 
cause damage. As the result of 
experimentation some authors have 
closed the peritoneal cavity com¬ 
pletely without drainage in cases in 
which it was known that some septic 
areas remained behind, depending 
upon the peritoneum to dispose of 
any sepsis after the chief focus of 
infection had been removed. While 
primary union often occurs in such 
cases, the author believes that at 
the present time it is best to use 
small capillary drainage apparatus 
for removing culture fluids from the 
septic site. 

DRAINAGE OF THE PERI¬ 
TONEAL CAVITY.— Because of at¬ 
mospheric pressure upon the abdom¬ 
inal contents, any free fluid within 
the peritoneal cavity has a tendency 
to follow the line of least resistance 
to the surface, and if this fluid is 
given direction by way of small capil¬ 
lary drains we fulfill the general indi¬ 
cations in drainage, but posture of 
the patient is an aid under some cir- 


26 


ABDOMEN, SURGERY OF (MORRIS). 


cumstances; and the Fowler position, 
in which the upper part of the body 
is raised in bed to an angle which 
will allow fluids to gravitate to the 
drain in the lower part of the 
abdomen, is at times very useful. 
The only objection to the Fowler 
position is the call for rather more 
work on the part of the heart in a 
very weak patient. 

In the upper part of the abdomen 
we have a natural mechanical situa¬ 
tion, aiding drainage from the bile- 
tract region, in what is known as 
Morison’s pouch, the space between 
the liver, above, and the stomach and 
colon, below. Blood, bile or septic 
fluids escaping into this pouch have 
a tendency to make their way directly 
to the surface at this point, instead 
of spreading into the general peri¬ 
toneal cavity below, and this tendency 
is so marked that a very little capil¬ 
lary drainage carried to the bile-tract 
region suffices to clear the area of 
culture media. It even allows us to 
do away with suturing the common 
bile-duct in many cases in which this 
has been opened for removing a cal¬ 
culus. 

Abdominal drainage is well con¬ 
ducted by any of the means described 
under the head of drainage apparatus, 
and the author feels that it is always 
best to employ capillary drainage, 
rather than drainage through tubes 
which carry no gauze wick. When a 
tube without gauze wick is filled with 
fluid, the column of fluid in the tube 
exerts hydrostatic pressure of con¬ 
siderable degree, which is met by the 
atmospheric pressure of the viscera, 
to be sure, but drainage through a 
simple tube cannot be so free as when 
fluids are guided through the tube by 
absorbent gauze with its high degree 


of capillary power. Drainage appara¬ 
tus should be carried as little as pos¬ 
sible among intestinal loops, because 
such drainage apparently acts as a 
foreign body, and the peritoneum 
rapidly throwing out lymph because 
of the offense seals in such drainage 
apparatus and deprives it quickly of 
its usefulness. 

If the abdominal work carries us 
to the pelvis, there is sometimes 
an inclination for the surgeon to 
add vaginal drainage, because the 
Douglas pouch represents the lowest 
part of the abdominal cavity, and one 
would naturally feel that fluids would 
all gravitate to this lowest point. 
This is not quite true, however, in 
practice, as atmospheric pressure has 
a tendency to force even pelvic fluids 
to the midline incision in the 
abdomen, with or without encourage¬ 
ment from capillary drains, and the 
advantage of depending upon drain¬ 
age through an abdominal incision 
rather than through a vaginal incision 
depends upon the comparative ease 
with which the area of the abdominal 
incision is kept aseptic. Drainage in 
the vaginal region is in an area much 
more difficult of maintaining in a 
degree of relative asepsis. 

The author formerly felt that it 
was an advantage to insert drainage 
apparatus at more than one point in 
the abdominal wall at points that 
seemed natural places for collection 
of peritoneal fluid, but of late years, 
in a series of many hundreds of 
abdominal operations sufficient to 
demonstrate the real requirements, 
he has found that one point for drain¬ 
age in the lower abdomen will suffice, 
and the only additional point used for 
drainage for many years has been in 
reference to Morison’s pouch, which 


ABDOMEN, SURGERY OF (MORRIS). 


27 


amounts practically to a separate 
cavity more distinct than the cavity 
of the pelvis so far as the question of 
the necessity for drainage devices is 
concerned. We need to give aid to a 
single incision drainage at times by 
the addition of posture. 

In order to carry out the principles 
of capillary drainage it is essential for 
one to be familiar with the mechanical 
principles involved, and to make fre¬ 
quent change of the external mass of 
gauze to keep the capillary drain at 
work within the abdomen. In cases 
in which fluids drained from the 
peritoneal cavity are irritating to the 
skin, the skin may be dried tem¬ 
porarily, and then covered in the 
vicinity with a thin layer, of collodion 
or of vaselin. In addition to the 
drain for the peritoneal cavity, it is 
important, on closing the abdominal 
incision, to leave a tiny wick drain 
for twenty-four hours, extending be¬ 
tween the muscle layer and the skin. 
This can rest between the sutures in 
such a way as to interfere not at all 
with final primary union. At the end 
of twenty-four hours, or at the time 
of the first dressing, it may be pulled 
out, and will be found to have drained 
out as a rule quite a little serum or 
free fat, or both, which would have 
been a menace as a culture medium. 
Excepting in patients with a veryt 
thin adipose layer, it is well to make 
it a rule to introduce this tiny drain 
at any convenient point between the 
sutures, and to remove it on the fol¬ 
lowing day. 

Drainage is indicated, in general, (1) 
where there is infection which in the ab¬ 
sence of drainage would persist or ex¬ 
tend; (2) where it is necessary to wall off 
by adhesions a portion of peritoneum; 
here the irritation results in adhesions and 
the formation of a pocket unconnected 


with the general peritoneal cavity. A 
commonly used drain consists of a rubber 
tube surrounded by gauze and this, in 
turn, by rubber protective. Wick may be 
passed into the inner tube and later re¬ 
moved, or the tube* may be emptied at 
short intervals by the insertion of a 
smaller tube and aspiration with a syringe. 
In situations where a soft drain would be 
compressed to the point of obliteration or 
be soon disarranged, a glass drainage tube 
may be employed, e.g., in the pelvis or 
some deep focus to be drained through a 
mass of intestinal coils. Mikulicz’s gauze 
envelop drain consists of a square of 
gauze pushed down into the wound, and 
into which gauze strip is packed. It is 
especially useful where, besides drainage, 
pressure packing for hemorrhage is also 
necessary. The inner packing may be re¬ 
placed at intervals. 

Removal of drainage should not be 
undertaken while infection is still present 
at the bottom of the cavity being drained. 
On the other hand, it must not be post¬ 
poned to a point where the discharge 
drained is solely that resulting from the 
irritation by the drainage device. Usually 
adhesions are sufficiently firm for the re¬ 
moval of the drain after two days. Some¬ 
times it can be removed in twenty-four 
hours. Editors. 

Drainage should be removed early 
in all patients who are slow to react 
from an abdominal operation. In no 
case should gauze be allowed to re¬ 
main in contact with the alimentary 
tract longer than twenty-four hours. 
Swope (Amer. Jour, of Obstet., Nov., 
1915). 

In applying the Ochsner treatment 
in septic abdominal states, the writer 
favors the Fowler position only in 
pelvic abscesses and in general peri¬ 
tonitis. A drain to the most de¬ 
pendent part of the abscess, in con¬ 
junction with turning the patient on 
his face and elevating the foot of the 
bed for ten-minute periods twice 
daily, aids in clearing the pelvis. In 
abscesses not in the pelvis, the Fow¬ 
ler position should not be used, but 
the patient turned toward the affected 
side, and once or twice a day turned 
over on the face to throw the pus 


28 


ABDOMEN, SURGERY OF (MORRIS). 


against the line of incision. A. M. 
Willis (N. Y. Med. Jour., May 29, 
1915). 

Drainage with the patient in the 
prone position tried out very success¬ 
fully. The patient is placed on the 
abdomen usually for 24 to 48 hours, 
with the head of the bed elevated 
about 10 to 12 inches. One pillow is 
placed under the lower part of the 
chest and one under the head. There 
are no spaces in the front of the ab- 
donieu to favor the formation of 
pockets, as there are in the pelvis and 
alongside the spine, and the pus is 
brought against a part of the ab¬ 
domen where blood-vessels and lym¬ 
phatics are not nearly as numerous. 
Placing the patient on the right side 
was found very efficient. A pillow is 
placed under the region of the liver 
and the patient is turned far enough 
over so that pus will drain from in 
front of the left kidney. Among 15 
cases of appendicitis treated in the 
lateral position there was no mortal¬ 
ity. Among 42 cases treated in the 
abdominal position there were but 2 
deaths. Among 47 cases treated in 
the Fowler position there were 5 
deaths. Hill (Annals of Surg., Ixvi, 
414, 1917). 

War surgery has taught what 
should be the 2 main principles of 
civil surgery: 1. Early and complete 
operation. 2. That secondary or 
mixed infection is worse than pri¬ 
mary infection. While the tissues of 
the body can, if given a fair chance, 
deal with one infection only, if that 
infection becomes a mixed one by 
entrance of organisms from outside, 
then the last state is worse than the 
first. If surgeons will take their 
courage in both hands, and will not 
be frightened by a little infection, 
leaving it to be dealt with by the 
natural resistance of the tissues to in¬ 
fection, and will give up the use of 
drainage tubes, they will not only 
find their results much better, but 
also their outlook on surgery totally 
changed. All that is necessary is to 
put something into the tissues which 
will keep a “passage” open but which 


does not leave an open “drain.” The 
writer puts in a piece of soft folded 
rubber—for instance, in an appendix 
abscess. This allows pus to come 
away, but will not leave an open 
“drain” by which secondary infec¬ 
tion of staphylococci, from the skin, 
or other organisms can gain en¬ 
trance. Hathaway (Brit. Med. Jour., 
June 29, 1918). 

HEMOSTASIS. —A few technical 
points belong to hemostasis in abdom¬ 
inal surgery. Where it is possible to 
use torsion instead of ligatures—and 
this covers very much of the field— 
we can avoid ligatures, the presence 
of 'which causes the peritoneum to 
thfow out plastic lymph in the vicin¬ 
ity for its protection, very much as 
the mollusk throws a layer of nacre 
over a grain of sand in the shell. 
Where it is necessary to use ligatures 
we avoid including much mass in the 
ligature, because, the larger the mass, 
the greater the tendency for the peri¬ 
toneum to throw out reparative 
lymph which will lead to adhesion 
formation subsequently. We have 
also to remember that the efforts of 
vomiting after an abdominal opera¬ 
tion have a tendency to pull off 
certain ligatures, and consequently 
we must leave a considerable mass of 
tissue outside of the knot. Such 
mass of tissue is not likely to slough, 
as some operators fear, because it is 
kept alive by lymph circulation in the 
vicinity, and has a tendency to grad¬ 
ually become absorbed in a very 
benign way, because of the fact that 
it is tissue belonging to the indi¬ 
vidual. Hemostasis of the cut margins 
of the alimentary tract cannot readily 
be obtained by ligating, and conse¬ 
quently we employ the suture here 
instead, for the most part, and snugly 
drawn running sutures suffice for the 
purpose. 


ABDOMEN, SURGERY OF (MORRIS). 


29 


Gauze moistened with saline solution 
is to be preferred for sponging during the 
operation. Larger, flat gauze sponges, 
previously warmed, are employed to cover 
and hold aside intestinal coils. Rubber 
tissue may with advantage be placed be¬ 
tween the gauze and peritoneum to 
minimize irritation of the latter and sub¬ 
sequent adhesions. Pressure with gauze is 
effectual in arresting capillary oozing. 

Permanent arrest of bleeding by the 
temporary pressure of a hemostat and 
clot formation cannot be relied on, as the 
clot may later be forced out when the 
blood-pressure rises to normal. Aside 
from ligature, the cautery is, in rare in¬ 
stances, required. In the case of deep 
vessels that cannot be ligated, but are 
caught with clamps, the latter may be left 
in place, surrounded by gauze and rubber 
tissue for two days, then cautiously re¬ 
moved. Gauze packing may likewise be 
left in situ for a time. Editors. 

EXTERNAL INCISIONS.—The 

ultimate success of an abdominal 
operation often depends largely upon 
the choice of the external incision, 
and we have two especial points to 
bear in mind: consideration of the 
best route for getting to any objective 
point within the abdominal cavity, 
and at the same time the best way 
for avoiding imperfect repair of the 
abdominal wall and unsightly scars. 

This includes a consideration of 
avoiding nerves which supply mus¬ 
cles, because a temporary or perma¬ 
nent paralysis of certain abdominal 
muscles was a very annoying post¬ 
operative complication before sur¬ 
geons began to give attention to this 
matter. To reach an objective point 
in the peritoneal cavity, and at the 
same time avoid the complication due 
to muscles cut transversely, we may 
practically cover the ground by stat¬ 
ing that it is well to plan to make 
separate division of each layer—skin, 
adipose tissue, fascia, muscle and 


parietal peritoneum—and, further, to 
make blunt dissection as far as pos¬ 
sible of each muscle, even though 
this sometimes leads to openings 
crossing each other at somewhat dif¬ 
ferent angles. Stretching of the 
muscle wound with the fingers, how¬ 
ever, does away with most of the 
awkwardness of a situation where 
split muscles, after blunt dissection, 
as it is called, lie at different angles. 

When, for any reason, it becomes 
necessary to cut transversely across 
a muscle we must mark well the 
point at which such transverse inci¬ 
sion was made for the purpose of 
making accurate repair subsequently, 
otherwise the muscles acting in their 
lines of traction during the course of 
the operation will smooth out angles 
more by transverse incisions, and it is 
difficult to restore these angles again. 
On general principles our incisions 
are to be made directly over the 
objective point, but because of the 
ease with which an incision is made 
into the abdominal cavity in the 
median line, and the ease with which 
such an incision is repaired, the mid¬ 
line incision should be used for per¬ 
haps the larger part of our abdominal 
work. 

The size of incisions will depend 
largely upon the operator. One must 
make as large an incision as he needs 
for working freely and safely, but, if 
experience allows an operator to 
make his incisions shorter and shorter 
safely in any particular field of 
abdominal work, the patient will have 
the advantage of less danger from 
subsequent hernia, less shock, and 
less noticeable scars. Small incisions 
are dangerous for the beginner, and 
plenty of room is desirable on his 
account, but he may adopt the middle 


30 


ABDOMEN, SURGERY OF (MORRIS). 


ground of beginning with a compara¬ 
tively small incision, and then enlarg¬ 
ing it as occasion requires. 

If the abdomen requires opening in 
two different localities at the same 
sitting, there is frequently an advan¬ 
tage in making two or more small 
separate openings, rather than ex¬ 
tending a large one to reach distant 
points, such as often occurs in cases 
of intestinal obstruction, where one is 
not sure of the point of the obstruc¬ 
tion. If through the first incision, in 
a case of obstruction, one does not 
readily reach the point at which the 
constriction occurs, he is likely to add 
much more to the serious condition 
of the patient if he makes a large 
incision and pulls the bowel out from 
that than he is if he makes more than 
one incision small, and then passes 
the bowel between his fingers at that 
point without drawing it out upon the 
abdominal wall. Special incisions 
will be noted in connection with cer¬ 
tain operations, the above covering 
only a general principle. 

When we have occasion to open 
the abdomen at the site of a former 
operation, it is well to carry the inci¬ 
sion through normal skin on either 
side of the scar line for two reasons: 
because of the advantage of removing 
the scar tissue in some cases, and 
because in opening at the site of an 
old scar one may run across adhesions 
of abdominal viscera of which he was 
not aware, and they may be injured. 
The safe way for entering along the 
site of an old scar, and for leaving the 
viscera in good condition for repair 
subsequently, is to go down through 
normal tissue on either side of the scar 
until muscle sheath is definitely 
reached, and then snipping muscle 
sheath until the muscle beneath is seen. 


The sheath can then be opened freely 
on either side of the scar without dan¬ 
ger. If there is any question about 
adhesions being present at just this 
point of dangerous character, we ex¬ 
tend the incision through the sheath of 
muscle to some point above or below 
the scar, where we may enter the peri¬ 
toneal cavity at a point free from ad¬ 
hesions, being extended at a free point 
large enough to admit the finger. The 
finger is then carried back along the 
peritoneal side of the scar line, and 
adhesions if present are separated. 
This having been done, the posterior 
sheath of the muscle and transversalis 
fascia and peritoneum are safely cut 
along the entire line of the scar, and 
the parts left in excellent position for 
correct apposition subsequently. 

In the typical vertical incision, or median 
postmuscular incision, no motor nerves or 
muscles are divided. Firm muscular pro¬ 
tection is assured by making the openings 
in the deep fascia to one side of the median 
line and retracting the rectus muscle out¬ 
ward. Laterally, the best incisions are of 
the muscle-splitting type, the fibers of each 
muscle encountered being separated longi¬ 
tudinally and the nerves identified and pro¬ 
tected. Transverse incisions are usually 
such only through the skin and superficial 
fascia, though Willy Meyer has recom¬ 
mended, for free access to the stomach, a 
transverse incision in which one or both 
recti are cut across and later reunited. 
Editors. 

The Perthes rectangular flap method 
is favored for many operations in the 
upper abdomen by the writer. An 
incision is made in or near the 
median line, beginning close to the 
xiphoid and running straight down 
nearly to the level of the umbilicus: 
here a turn is made and the incision 
carried horizontally to the anterior 
axillary line. In the vertical part all 
tissues are divided down to the 
posterior sheath of the rectus. At 
the lower end, the second and third 
fingers of the left hand are passed 


ABDOMEN, SURGERY OF (MORRIS). 


31 


beneath the rectus until the outer 
edge of its sheath is felt. Then 2 
parallel rows of horizontal sutures 
are passed through the rectus and 
overlying fascia and tied. Between 
them the muscle is cut and the hori¬ 
zontal incision completed, the corner 
of the flap being next raised with a 
sharp retractor while the operator 
separates the skin and muscle flap 
from the underlying aponeurotic layer 
in the direction of the costal arch. 
This is done with a gauze pad. 
When the two intercostal nerves with 
their associated vessels appear this 
part of the dissection is completed 
and the abdomen is opened by an in¬ 
cision through the aponeurosis and 
peritoneum parallel to the costal arch 
and close to it. The incision gives 
free access to the upper abdomen, 
preserves innervation of all the tis¬ 
sues, has the skin and peritoneal in¬ 
cisions at different points, and per¬ 
mits extension in either direction. 
Willy Meyer (Jour. Amer. Med. 
Assoc., Nov. 17, 1917). 

For operating on the rectum and 
on the pelvic ureter, the author ad¬ 
vises a skin incision beginning at the 
symphysis pubis, running in the mid¬ 
line upward for about 2 inches, 
then diagonally upward and outward 
toward the anterior superior spine. 
The fascial incision repeats the direc¬ 
tion of the skin incision. The rectus 
muscle, thus exposed, is freed and 

divided between clamps. Care is 

taken to push back the epigastric ves¬ 
sels from the posterior surface of the 
muscle, and to clamp, divide and 

ligate them separately. The fascia of 
the transversalis and obliquus internus 
and the peritoneum are then divided 
by an incision which repeats the 
direction of the skin incision. In 
closing, the peritoneum, with the 

transversalis and internal oblique fas¬ 
cia, is sutured by a running stitch. 
The divided rectus may be approxi¬ 
mated by mattress sutures. The an¬ 
terior sheath of the rectus and fascia 
of the obliquus externus muscle are 
closed by overlapping. J. W. Church¬ 
man (Annals of Surg., Feb., 1918). 


One must always be on guard . 
against small hernial protrusions into 
scar sites, and a small knuckle of 
bowel may be adherent in such pro¬ 
trusions without having led to symp¬ 
toms sufficient for one to suspect its 
presence. Ordinarily, on reaching the 
peritoneum or subperitoneal fat, it is 
not necessary to pick it up and divide 
between forceps, if one has reason to 
believe that no adhesions occur at 
that point. Under ordinary circum¬ 
stances, the various layers of the 
abdominal wall having been opened 
down to the peritoneum, or peritoneal 
or subperitoneal fat, these structures 
may be made tense between two 
fingers of one hand, the two points of 
scissors then introduced into this 
tense area nearly parallel with the 
plane of the abdominal wall, and an 
entrance into the peritoneal cavity 
made with celerity. This opening can 
then be enlarged to any desired extent 
with the scissors, or in many cases by 
stretching. 

Closure of the abdominal incision 
may also be described in a general 
way to cover most of the principles 
involved. The first suture of the 
peritoneal incision should consist of 
the finest catgut, because, the smaller 
the strand of catgut, the less peri¬ 
toneal irritation from the suture, and 
consequently less tendency to adhe¬ 
sions of the omentum which reaches 
out to wall-in points of irritation 
within its range. A fine strand of 
catgut is also a distinct advantage 
along the line that would be touched 
by the liver, which slides along the ab¬ 
dominal wall with each respiratory 
movement. 

Placing a small, flat pad underneath the 
wound is helpful in holding down the in¬ 
testines while the peritoneum is being 


32 


ABDOMEN, SURGERi" OF (MORRIS). 


sutured; the pad is withdrawn when the 
peritoneal suturing is nearly finished. A 
continuous suture, with the needle in¬ 
serted about % inch from the margins, the 
serous surfaces of which should be held in 
apposition by stretching between hemo- 
stats, is used for the peritoneum. 

Murphy proved that suturing an ab¬ 
dominal incision in layers gives a more 
satisfactory and stronger looking wound 
histologically than the en masse suture. 
Wounds sutured in layers were the 
stronger after two weeks, when the 
strength of the scar was tested by actual 
pull. The time necessary for repair is, 
moreover, decreased. Violent manipula¬ 
tions of the edges of an abdominal in¬ 
cision must be carefully avoided. Editors. 

In experimental work with animals 
in the course of which the author 
closed peritoneal incisions with rather 
large strands of catgut or silk for 
the purpose of saving time, he ob¬ 
served that adhesions of intraperi- 
toneal structures of some sort along 
the suture line are practically uni¬ 
versal. He observed that the smaller 
the strand of catgut, the less post¬ 
operative adhesions occurred, and 
although such adhesions commonly 
become absorbed they remain just 
often enough in practical surgery to 
make it a very general point to avoid 
them as much as we can. Very little 
strength indeed is required for ap¬ 
proximating peritoneal margins, and 
a suture which would be absorbed in 
forty-eight hours is all that is re¬ 
quired, and a very small strand at 
that. 

It is the sheaths of the muscles 
upon which we depend for strength 
when closing an abdominal incision. 
Suturing of the sheaths of the mus¬ 
cles is carried out neatly by using a 
continuous suture of chromic gut 
along the posterior sheath first, and 
then returning along the anterior 
sheath without introducing sutures 


into the muscle itself at all when the 
incision is made in the median line of 
the abdomen, and the same principle 
can be used in several parts of the 
abdominal wall. Muscle belly does 
not hold sutures so well as muscle 
sheaths, and there are feAV situations 
where it is necessary to introduce 
sutures into the muscle belly. By 
bringing the posterior and anterior 
sheaths of muscles into their re¬ 
spective normal positions, atmos¬ 
pheric pressure carries the bellies to¬ 
gether much more evenly than we 
could do it with sutures. 

Several fanciful methods for sutur¬ 
ing the various structures of the 
abdominal wall have been described, 
but it is not necessary to do anything 
more than to leave structures as we 
found them as nearly as possible. 
Where one can catch the transversalis 
fascia along with the posterior sheath 
of a muscle in a suture, it is well to 
do so. 

In cases in which there may be 
need for reopening the abdomen sub¬ 
sequently, interrupted sutures of the 
muscle sheath for a part or all of the 
way are of advantage, because then 
we reopen only to the extent neces¬ 
sary. Where a drain has been left in 
an incision, the suture running up to 
the drain may be followed by a pro¬ 
visional interrupted suture, if it is 
desired to close the incision com¬ 
pletely when the drain is removed, 
but this is seldom necessary, for 
proper suturing up to the small 
drains which are now in vogue will 
allow of the walls falling together 
naturally enough when the drain is 
removed. 

One disadvantage of carrying the 
sutures through muscle tissue is the 
danger of the sutures cutting through 


ABDOMEN, SURGERY OF (MORRIS). 


33 


such tissue when the patient vomits. 
This space then fills with blood which 
must be replaced by new tissue cells, 
and it usually is so replaced if the 
blood, as a culture medium, does not 
become exposed to infection from the 
suture, or some other source. For 
the muscle-fascia suture, chromic cat¬ 
gut or kangaroo tendon is desirable, 
because they last so much longer than 
simply prepared catgut, but not so 
long as to constitute a source of irri¬ 
tation, as a rule. Kangaroo tendon 
seems to be much more benign than 
chromic catgut, and it lasts rather 
longer in the tissues, unless the cat¬ 
gut has been chromicized in a way 
which makes it too hard. 

In large wounds, figure-of-eight sutures 
of silkworm gut are also sometimes used, 
catching all layers superficial to the peri¬ 
toneum. A few days later, when the dan¬ 
ger of vomiting or other unusual strain 
has passed, and the fasciae united, they may 
be taken out again. The deeper loop of 
the figure-of-eight embraces the deep 
fascia and the superficial loop all the re¬ 
maining tissues over it. If used as per¬ 
manent rather than tension sutures, these 
sutures should be inserted about H inch 
apart. Editors. 

Where one needs to introduce in¬ 
terrupted tension sutures, there is 
nothing better than kangaroo tendon 
passed through muscle sheath, care¬ 
fully avoiding the fat, into which no 
tension suture should ever be intro¬ 
duced. When closing the adipose 
layer of the abdominal wall, it is ex¬ 
tremely important to avoid allowing 
any sort of suture to enter any fatty 
structure. The reason for this is 
because the entrance of any suture, 
or even the needle carrying the suture, 
into the adipose layer allows free oil 
to escape and to follow the course of 
the needle .or suture, and such free 
oil, according to the principle of 


hydrostatics, will begin to travel, 
opening up lines for infection in many 
cases. 

Where a very small amount of 
oil is set free along suture lines it is 
no doubt absorbed in many cases, 
but nevertheless always introduces a 
danger which is unnecessary, because 
we can apply a principle in mechanics 
commonly overlooked which allows 
us to do away with any suturing 
through any adipose layer of the 
abdominal wall. This principle is the 
one which is employed by the boy 
who lifts stones after pressing down 
upon them a disk of wet leather to 
which a string is attached in the 
middle. It is the principle of making 
use of atmospheric pressure. When 
the suturing of muscle sheath has 
been completed, if the adipose layers 
of the abdominal wall are then 
pressed together with the hands, they 
adhere firmly under atmospheric pres¬ 
sure the moment that the skin is 
sutured. It is somewhat difficult at 
the end of forty-eight hours to sepa¬ 
rate fatty tissues along the original 
line, if one has occasion for any reason 
to re-enter the abdominal cavity. The 
question of suturing the adipose layer 
then may be disposed of by saying 
simply. Do not suture adipose tissue 
at all. 

To overcome in most instances the 
difficulties of intra-abdominal opera¬ 
tion in stout patients, the writer re¬ 
sorts to a large excision of skin and 
fat from the overweighted abdominal 
wall, removing a skin section either 
in the transverse or in a vertical 
direction corresponding to or at right 
angles with the incision, about 8 or 
10 inches in length by 3 or 4 inches 
in width. This does away with the 
thickness of the wall down to the 
fascia, while from the fascia inward 
the difference between different ab- 


34 


ABDOMEN, SURGERY OF (MORRIS). 


domens is not great. If the patient 
is excessively fat, one will then 
naturally do a regular lipectomy op¬ 
eration. Kelly (Annals of Surg., 
March, 1911). 

In suturing the skin the use of the 
subcuticular suture avoids scarring 
with a needle, and it also avoids the 
danger of making stab cultures of the 
Staphylococcus albus, which is found 
regularly as an inhabitant of the hair- 
follicles of the skin. Where very 
heavy abdominal walls are to be sup¬ 
ported, we may fortify the skin 
sutures by placing squares of zinc 
oxide plaster at a short distance from 
the line of incision on either side of 
the incision, and then lacing these 
squares together through eyelet holes 
placed in the margins. 

To avoid infecting the wound with 
the lacing, a thin layer of dressing is 
first placed next the wound, and then 
the squares of adhesive plaster laced 
together over this. We thus avoid 
altogether the necessity for introduc¬ 
tion of deep through-and-through 
sutures, which in the past have been 
commonly used for supporting over¬ 
heavy abdominal walls. 

Deep catgut sutures of the ab¬ 
dominal wall sometimes become ab¬ 
sorbed before there is perfect union. 
To overcome this, the writer uses a 
silkworm gut slip-knot or running 
knot method. A Reverdin needle is 
passed through the edges of the two 
recti muscles; the middle of a strand 
of silkworm gut is pressed into the 
eye and the needle drawn back 
toward the operator. The two ends 
of the gut are then passed through 
the loop to form a slip-noose. Be¬ 
fore tightening this a piece of silk 
thread is passed through the loop and 
its ends knotted together. This 
serves later to withdraw the loop. 
The noose is then pulled tight. The 
two ends of silkworm gut are now 


passed through the skin margin near¬ 
est the operator through two needle 
holes made in a line parallel to the 
incision but about 2 to 3 cm. from its 
edge:. The ends are then knotted. 
The skin margins not being brought 
closely together by the ends of the 
slip-noose, in the case of subcutan¬ 
eous suppuration they can be sep¬ 
arated without disturbing the deep 
sutures. When all the deep sutures 
are completed the cutaneous sutures 
are placed. About the tenth or 
eleventh day the slip-noose can be 
removed. This is done by cutting the 
two ends of the deep sutures im¬ 
mediately under the knot. Traction 
is then made on the silk thread and 
the loop easily withdrawn. Chaput 
(Presse med., July 19, 1917). 

To avoid unsightly scars of the 
skin due to stretching out and widen-- 
ing of the scar line after union is 
complete, we put a single layer of 
gauze or chenille over the line of 
incision, and then pour on collodion. 
This collodion-gauze dressing may 
remain in place for two or three 
weeks if one wishes, and it consti¬ 
tutes a very neat resource for avoid¬ 
ing scarring of the abdominal wall for 
people who have a perfectly legiti¬ 
mate vanity in the matter. 

Above the navel the transverse in¬ 
cision offers the most adequate ex¬ 
posure of the various pathologic con¬ 
ditions. The gall-bladder, stomach, 
and even the appendix, if not adher¬ 
ent in the pelvis, can readily be dealt 
with. In most instances retraction 
of the abdominal wall, both upward 
and downward, is possible so that 
good exposure is usually obtained. 
By supplementing this incision with 
the near midline vertical incision 
when necessary, one is afforded the 
most ideal exposure it is possible to 
obtain. R. E. Farr (Trans. Minn. 
State Med. Assoc.; Jour. Amer. Med. 
Assoc., Sept. 21, 1918). 

The transverse incision used over 
8 or 10 years by the writer, is par-' 


ABDOMEN, SURGERY OF (MORRIS). 


35 


ticularly advantageous in some cases 
of gall-bladder trouble or diseases of 
the ducts; also in diseases of the 
stomach and pylorus, when one is 
not sure of the diagnosis. It gives 
splendid access to the organs in the 
upper abdomen. W. H. Magie 
(Trans. Minn. State Med. Assoc.; 
Jour. Amer. Med. Assoc., Sept. 21, 
1918). 

EXPLORATORY OPERA¬ 
TIONS. — Very few exploratory 
operations should be done in abdom¬ 
inal surgery. The method no doubt 
makes diagnosis easier for the sur¬ 
geon, but a more difficult matter for 
the patient, and it is highly important 
to make use of all available diagnostic 
resources before taking active steps 
in an operative way. Where an ex¬ 
ploratory operation really needs to 
be done, however, it is best to make 
as small an incision as will suffice for 
the purpose. There are cases, for 
instance, in which we need to know 
if adhesions in the bile-tract region 
are complicating a loose kidney, or an 
appendix operation; and an explora¬ 
tory operation, if small, for the pur¬ 
pose of determining that point is 
frequently in order. Then again, 
after traumatisms and perforations, 
the peritoneal cavity can contain 
blood, chyme, fecal matter or gas, 
which might be overlooked if one 
were too conservative about making 
exploratory incisions. In the pres¬ 
ence of traumatic shock, ordinary 
diagnostic resources may fail us, and 
lead us to employ what older sur¬ 
geons are apt to consider the resource 
of the tyro, namely, the exploratory 
incision. 

To dress the wound a rectangular pad 
consisting of ten layers of gauze, fixed 
with straps of adhesive, and covered by 
an abdominal binder, constitutes a suffi¬ 


cient dressing after short abdominal oper¬ 
ations, though some operators use silver 
foil, collodion, an antiseptic powder such 
as aristol, or a wet dressing as an im¬ 
mediate covering for the incision. Where 
drainage has been instituted or infection 
is apprehended, some absorbent material 
may be also applied. On the seventh to 
the tenth day non-absorbable sutures may 
be taken out, but adhesive-plaster should 
again be firmly applied. Indeed, the ad¬ 
hesive and binder should be continued, as 
a rule, for four weeks after the operation, 
though healing is sufficiently secure for 
the patient to rise from bed in two weeks. 
Editors. 

PERITONEAL ADHESIONS.— 

Perhaps the most potent single factor 
in surgery of the abdomen relates to 
peritoneal adhesions. They lead to a 
large iTart of the constipation from 
which the public is suffering; to an 
extremely important part of the 
obscure dyspepsias; to various local 
areas of pain and tenderness, and fre¬ 
quently enough to acute disasters. 
The surgery of peritoneal adhesions 
belongs to the surgery of the future 
for the reason that such adhesions are 
commonly overlooked by diagnosti¬ 
cians at the present time, and only a 
trifling percentage of cases of gastric 
and bowel disturbances are placed 
where they belong in cause and effect 
relationship to adhesions. The new 
work of filling the stomach with bis¬ 
muth solution and then making fluoro¬ 
scopic examination to determine points 
of interference with gastric motility is 
now allowing us to make the diagnosis 
of gastric adhesions freely. 

In post-mortem work we find peri¬ 
toneal adhesions at some point in 
pretty much every abdominal cavity, 
in adults at least, and the argument 
that these have not caused trouble 
during the patient’s lifetime includes 


36 


ABDOMEN, SURGERY OF (MORRIS). 


the idea that the patient is to have 
made the diagnosis himself, and to 
have informed his physician in the 
ordinary course of narration of his 
troubles. In this article the subject 
of peritoneal adhesions can receive 
nothing more than brief treatment, 
but it may be disposed of in a general 
way which includes most of the prin¬ 
ciples. 

The surgeon has to consider the 
matter of separating peritoneal adhe¬ 
sions when they are found to give 
trouble, and to prevent their recur¬ 
rence. He has to take steps in his 
operative work which will guard 
against the formation of adhesions 
resulting from his work. On the 
other hand, he has to resort to the use 
of peritoneal adhesions established 
for his own purposes in many parts 
of abdominal work. In cases in 
which we wish to make use of peri¬ 
toneal adhesions it is important to 
scarify the peritoneum in the vicinity 
with the point of a needle in order to 
make sure of the free exudation of 
lymph together with destruction of 
part of the endothelial layer. The 
desirability of this scarification is ex¬ 
perienced in laboratory work where 
one is working with animals, and it 
leads to the feeling that sometimes we 
do not obtain adhesions enough for 
safety in some kinds of bowel work, 
unless scarification has insured their 
production. 

When we wish to prevent the 
re-formation of adhesions which had 
formed in advance of operation, many 
resources are of more or less value, 
but the author has chiefly depended 
upon two. These consist in the use 
of the aristol film, and the Cargile 
membrane made of the sterilized 
peritoneum of the ox. Aristol film is 


obtained by sprinkling aristol freely 
over the oozing surface from which 
adhesions have been separated, press¬ 
ing the aristol upon these tissues 
firmly with a pad of gauze, and then 
leaving the area exposed to the air 
for a moment until the lymph-coagu- 
lum engages most of the aristol in its 
mesh. This presents a mechanical 
obstacle to the re-formation of adhe¬ 
sions. The author has found aristol 
in the tissues of animals after ex¬ 
perimentation, several months after 
operation. This material probably 
disappears in time through slow 
liquefaction in the fat of cells which 
are undergoing retrograde metamor¬ 
phosis. 

To prevent the re-formation of peri¬ 
toneal adhesions by using Cargile 
membrane, this material is laid upon 
oozing surfaces from which adhesions 
have been separated, and it may be 
caught at several points with strands 
of very fine catgut in case it does 
not adhere well enough naturally. 
Fingers and instruments must be 
very dry while applying this animal 
membrane; otherwise, it has a tendency 
to adhere to the fingers and instru¬ 
ments, rather than to the tissues of the 
patient. Cargile membrane is best 
transferred from a pad of dry gauze to 
the incised tissues. Animal membrane 
used in this way acts like the aristol 
film in presenting a mechanical obsta¬ 
cle to readhesion, but, unlike the aristol 
film, it has a tendency to undergo 
very rapid absorption in the peri¬ 
toneal cavity, remaining sufficiently 
long, however, as a rule, to serve as 
a conductor for new endothelium 
beneath its protecting surface. Lubri¬ 
cating adhesion areas with sterile oil at 
the time of operation is favored by 
some surgeons, on the ground that per- 


ABDOMEN, SURGERY OF (MORRIS). 


37 


istahis keeps oiled tissues moving too 
freely to allow of adhesions. 

Adhesions for the most part under¬ 
go absorption by lymphatics under 
ordinary physiologic conditions, but 
where there has been much disturb¬ 
ance of tissue, infective or traumatic, 
the connective tissue which replaces 
the reparative lymph may remain 
permanently. It may act in various 
ways: by inhibiting peristalsis of the 
bowel and causing constipation, or 
exposing the patient to the danger 
of angulation of the bowel at adherent 
points. Adhesions may cause local 
irritation and discomfort only, or they 
may lead to complete strangulation 
of any of the tubular structures. 
They may become pulled out into 
long strands which ensnare the bowel, 
or which roll the omentum into 
abnormal positions, and they may 
prevent the normal gliding of viscera, 
and give rise to distant reflex dis¬ 
turbances. 

In separating recently formed adhe¬ 
sions, it is best to separate them in as 
limited a way as will suffice for the 
completion of our work. The reason 
for this is because recently separated 
new adhesions are prone to re-form 
immediately in spite of all our efforts, 
and they may re-form in such a way 
as to be more injurious than when 
gradually arranged according to na¬ 
ture’s plans. 

To avoid the danger of formation 
of adhesions which were not present 
at the time of an operation we avoid 
rough handling of the peritoneum, 
which not only increases operative 
shock, but which stimulates the peri-, 
toneum to throw out an undue 
amount of lymph. The danger of the 
formation of such adhesions following 
traumatism produced by the operator 


is sometimes greater than the danger 
from adhesions which form under 
local septic conditions. 

When in the course of operative 
work it becomes necessary to with¬ 
draw loops of bowel, omentum, or 
other intra-abdominal structures, it is 
important to prevent them from be¬ 
coming dry, chilled or exposed to the 
vast numbers of bacteria constantly 
falling upon them from the air, and 
this is obviated by covering exposed 
surfaces with a thin sheet of rubber 
dam or of gutta-percha tissue while 
we are at work. Gauze as a protect¬ 
ive agent is objectionable, because it 
injures the endothelial surfaces at 
once unless it is quite wet with saline 
solution, and has a special tendency 
to cause subsequent adhesion forma¬ 
tion. 

Some peritoneums do not form 
adhesions of consequence, even under 
marked provocation, while in other 
cases they appear despite all precau¬ 
tions. Consequently in abdominal 
surgery we must always have in mind 
the possibility of adhesion formation 
which may nullify our best efforts in 
an operative way. Traumatism of 
the peritoneum is particularly to be 
avoided when we wish to sponge out 
fluids from the peritoneal cavity, and 
this sponging can often be done be¬ 
tween the fingers of the operator’s 
two hands. He places his hands 
about the field which is to be sponged 
in such a way as to make a little well 
down to the fluid, and the assistant, 
carrying gauze into the abdominal 
cavity, brushes the gauze repeatedly 
against the fingers of the operator, 
rather than against the delicate peri¬ 
toneum. 

The two points at which we need 
to open the peritoneal cavity most 


38 


ABDOMEN, SURGERY OF (MORRIS). 


often for relief of adhesions are in the 
bile-tract region and in the cecal 
region. The incision for reaching 
adhesions in the bile-tract region is 
commonly made along the free border 
of the ribs over the adhesion area, 
and in the cecal region the ordinary 
incision for reaching the appendix 
suffices. 

Specially prepared membranes and 
other foreign bodies are useless for 
the prevention of adhesions. Thor¬ 
ough asepsis and all possible avoid¬ 
ance of trauma and exposure to air 
are the main desiderata. Sound 
methods of preventing or treating 
troublesome adhesions consist in 
covering denuded areas with peri¬ 
toneum, suturing a part of the mesen¬ 
tery or omentum between the 2 sur¬ 
faces, or holding the latter away 
from each other after the adhesions 
have been cut by shortening the nor¬ 
mal supports of the organ or sutur¬ 
ing it or its supports to some other 
peritoneal surface. In marked ad¬ 
hesion involving only a loop of intes¬ 
tine, the adhesion should be left alone 
and the bowel short-circuited above 
and below by a lateral anastomosis 
between the two limbs. R. C. Coffey 
(Jour. Amer. Med. Assoc., Nov. 29, 
1913). 

Many desperate adhesion cases can 
be greatly benefited by postural treat¬ 
ment after the adhesions have been 
broken up at operation. Report of a 
case in which before wound closure 
the abdomen was filled with saline 
solution. As soon as the patient 
reacted from the anesthetic she was 
placed in a sitting position, and kept 
at least partially upright until she 
left the hospital. She was still well 
4 years later. This method requires 
that all or nearly all the adhesions 
be broken up, in order that the ab¬ 
dominal contents may sag as much 
as they are likely to immediately 
after the operation. Reichelderfer 
(Surg., Gyn. and Obstet., Dec., 1913). 

Satisfactory results reported from 
the use of omental grafts to cover 


raw surfaces after separating ad¬ 
hesions between adherent coils. The 
free border of the omentum is used. 
No more tissue than is actually neces¬ 
sary should be removed, but the 
transplant should be large enough to 
cover the raw area and project be¬ 
yond its margins on every side. The 
grafts are anchored with fine catgut 
sutures. L. Freeman (Annals of 
Surg., Jan., 1916). 

In 400 celiotomies, to prevent ad¬ 
hesions, the writer used a solution of 
sodium citrate and sodium chloride, 
of each 2 parts, in water 100 parts; 
all the sponges and gauze pads were 
moistened with this solution. Sax¬ 
ton Pope (Annals of Surg., Feb., 
1916). 

Adhesions tend to disappear spon¬ 
taneously if left alone. Infection 
seems to be the most important etio¬ 
logical factor; trauma intensifies its 
effect. Postural treatment is an im¬ 
portant question in minimizing the 
symptoms of adhesions. Omental 
grafts may be used in covering raw 
surfaces, but never in the presence 
of infection. The use of sodium 
citrate or of oil does not seem to be 
justified. Foreign bodies, such as 
Cargile’s membrane, in themselves 
produce adhesions. Hematomata are 
a cause of adhesions. The cautery 
is a useful preventive agent. Section 
of nerves, such as may occur in the 
right rectus incision, predisposes to 
adhesions. J. F. Corbett (Surg., 
Gynec. and Obstet., xxv, 166, 1917). 

INTESTINAL SUTURES.— 

Operations on the intestinal tract, 
despite their number and variety, can 
be reduced to a few simple steps of 
technique of which the most impor¬ 
tant element is the application of 
sutures and other retentive apparatus. 

In excision the principal stage of 
the operation is with the insertion of 
sutures. In primary anastomoses the 
application of the suture constitutes 
most of the operation. The cutting, 
consisting of making a communicat- 


ABDOMEN, SURGERY OF (MORRIS). 


39 


ing opening after the suturing, is 
partly done. A general outline of 
suturing and its substitute procedures 
is therefore necessitated. 

To secure union in most wounds of 
the bowel a continuous suture of fine 
catgut is first passed through both 
mucous and muscular coats, and the 
peritoneum is closed over all with a 
continuous Lembert suture of fine silk. 

Silk or linen thread are necessary 
for all sutures of the bowel which 
are to hold more than a few hours, 
for the reason that catgut is digested 
very quickly, if it enters the secret¬ 
ing glands of the bowel, and it is 
commonly taken up also with great 
rapidity by the peritoneum. This two- 
plane suture known as the Czerny- 
Lembert is the evolution of years of 
intestinal surgery, and is so firm as 
to prevent any possibility of leakage, 
but the apposition of the two peri¬ 
toneal surfaces insures peritoneal 
union almost immediately. 

In most cases it is best to scarify 
the peritoneum with the point of a 
needle wherever peritoneal adhesion 
is desired. This scarification with 
the needle insures the exudation of a 
large amount of reparative lymph. 
Any narrowing of the intestinal 
caliber under this suture is for the 
most part temporary, as expansion of 
the bowel will take place at that point 
later, and even the loss of a third of 
its circumference does not lead to 
actual stenosis. 

Any operation which consists in 
the closure of a wound in the long 
axis of the bowel involves in general 
no different suturing. This applies 
also to certain operations for pyloro¬ 
plasty and gastroplasty when a trans¬ 
verse incision is changed into a 
vertical one with a resulting increase 


of caliber. Whenever a cut surface 
of intestine does not enter into the 
restoration of continuity, it must be 
closed by a suture in the same way 
and under the same principle as 
linear wounds. Sutures of this type 
are applied to the cut surface of the 
stomach or intestine when these do 
not enter directly into anastomosis. 
In pylorectomy for cancer by Bill¬ 
roth’s first method the cut stomach is 
simply sutured down to a point which 
makes the caliber the same as the 
caliber of the cut duodenum. A cut 
end of intestine may also be closed 
by Lembert sutures, for the principle 
remains always the same. 

Peritoneal or mesenteric flaps are 
of substantial value for suture insuffi¬ 
ciency in all abdominal operations. 
According to the writer, omental 
flaps, on the other hand, are not de¬ 
serving of much attention. The first 
2 can take the place of the Lembert 
seromuscular suture, the last cannot. 
A striking diffarence in the results 
has been observed by the writer. 
Sasaki (Deut. Zeitsch. f. Chin, cxiii, 
62, 1913). 

For the sterilization of ligatures 
and sutures which must remain within 
the wound, the writer uses, in prefer¬ 
ence to the method of Claudius, a 
solution made of iodine, 1 per cent., 
and iodide of potassium, 1.75 per 
cent. The whole of the iodine is thus 
taken up, a darker and stronger solu¬ 
tion results, and catgut soaked in this 
for 10 days or more is almost black 
in color, and so strongly permeated 
by iodine that it is exceedingly dif¬ 
ficult to infect it. Moynihan (Brit. 
Jour, of Surg., July, 1920). 

When two cut surfaces are to be 
directly united by so-called end-to- 
end anastomosis the double plane of 
suture is applied as before, but the 
exigencies here are such that it is 
sometimes advisable to insert some 


40 


ABDOMEN, SURGERY OF (MORRIS). 


of the peritoneal sutures first. Thus 
the serous sutures are placed for 
about one-half the extent of the open¬ 
ing to be closed; then the deep pene¬ 
trating layer is inserted for the entire 
circumference, and finally the balance 
of the serous sutures are inserted. 

This plan of suturing is followed in 
a great variety of procedures, and as 
a rule for end-to-end anastomoses and 
implantations and secondary suturing 
in general. In primary anastomoses 
the principle is the same, some of the 
suturing being done in the interest of 
accurate coaptation before the anasto¬ 
motic opening is made. Thus, the parts 
to be joined having been placed in jux¬ 
taposition, with the fingers or with 
•clamps, the two portions of gut are 
first joined by a number of serous 
sutures, about half the number to be 
required eventually. The opening is 
then made and the all-embracing layer 
of continuous catgut serves to unite 
the edges of the same, after which the 
serous suture is completed. 

To prevent small masses of mucosa 
from pouting beyond the suture line 
while invaginating the mucosa by the 
ordinary methods of suture, the writer 
passes the suture from the mucosa out¬ 
ward through all the coats of the in¬ 
testine, instead of from without in, as 
is usually done. V. Schmieden (Zen- 
tralbl. f. Chir., April 15, 1911). 

McGraw Ligature. —A loop of 
bowel is brought against the portion 
of stomach with which it is to be con¬ 
nected, and the two structures are 
fastened together with a continuous 
durable Lembert suture for a distance 
of two and one-half inches. The 
stomach and bowel are then fastened 
together with a McGraw strand of 
solid rubber introduced with a large 
needle, preferably the Hagedorn full- 
curve type. The needle is passed 


through the wall of the stomach to 
the lumen, and then brought out 
again at a point two inches away. 
The needle traverses the wall of the 
intestine in the same way. The 
rubber strand then being drawn tight 
is tied in such a way as to constrict 
the included parts as snugly as pos¬ 
sible. The elastic-rubber knot is still 
further held by tying it with a strand 
of silk or linen. The next step com¬ 
pleting the operation consists in ap¬ 
proximating the portions of stomach 
and bowel which were left free after 
the preliminary suturing was done. 
The McGraw ligature was devised 
originally for gastroenterostomy, but 
is useful as well for enteroenteros- 
tomy. 

Murphy’s Button. —Wherever great 
speed in operating is a desideratum 
Murphy’s button gives an advantage, 
and if it were not for the fact that 
buttons are sometimes retained, or 
that they sometimes give rise to com¬ 
plications per sc, a very large part of 
our intestinal anastomosis work could 
be done with the aid of this ingenious 
resource. 

Two-stage Operations. —Some of 
the procedures for establishing gas¬ 
trostomy, enterostomy and colostomy 
are performed in two stages, the delay 
being for the purpose of allowing 
adhesions to form about the incisions 
and thereby protect the peritoneal 
cavity. Any operation whatever in 
which the external wound is not com¬ 
pletely closed may become a two- 
stage procedure if a special operation 
is necessary to close the wound. As 
a rule, however, a considerable inter¬ 
val elapses in such cases, too long in 
fact to enable us to regard it as a 
single operative intervention. When 
Avounds are closed outright there is a 


ABDOMEN. SURGERY OF (MORRIS). 


41 


possibility that they may at once 
require reopening for hemorrhage or 
sepsis. Hence, despite modern asepsis 
which has enabled us to operate so 
extensively in one stage, the abdom¬ 
inal operator is constantly exposed to 
the possibility of operating in succes¬ 
sive stages. 

SURGICAL DISEASES OF THE 
STOMACH.—We shall first enumer¬ 
ate the disorders in which surgical 
procedures are necessary, and then de¬ 
scribe under a special heading the va¬ 
rious operations resorted to. 

Gastric and Duodenal Ulcers.— 
These require a variety of surgical pro¬ 
cedures at various stages of their de¬ 
velopment. Recent or older ulcers 
may cause fatal hematemesis, per¬ 
forative peritonitis, and crippling ad¬ 
hesions. From their location near the 
pylorus, actual or healed ulcers may 
cause pyloric stenosis. It must not 
be forgotten, however, that gastric 
and duodenal ulcer is a malady 
largely amenable to medical treat¬ 
ment, some forms not requiring sur¬ 
gery at all, but surgical intervention 
is indicated just as soon as medical 
resources lose efficiency, and at an 
earlier period than is customary as 
yet. The better diagnoses made by 
physicians in late years, and the ex¬ 
tremely satisfactory surgery of the 
present day bring the question of 
time for operation to a point which 
can generally be agreed upon by 
expert physicians and surgeons. 

Gastric ulcers are frequently multi¬ 
ple, and unless one is aware of this 
fact he may overlook others while 
caring for the first one which appears 
in the course of an operation. An 
active ulcer of the stomach may be 
surrounded by latent ulcers, or by 
scars which need excision, or which 


call for gastroenterostomy quite as 
much as the acute condition. 

Perforating ulcer of the stomach is 
the one most often calling for imme¬ 
diate operation, while the chronic 
changes of the stomach due to scarring 
from old ulceration allow of more de¬ 
liberate action. 

The so-called bleeding ulcer with¬ 
out induration or tendency to per¬ 
foration, while chiefly medical, some¬ 
times calls for surgical relief, and it 
is sometimes very difficult to find the 
bleeding point; but, if the stomach is 
opened at a point not far from the 
pylorus, pressure of the finger upon 
various folds and rugje or gentle 
wiping with a small gauze pad will 
excite hemorrhage anew. The ar¬ 
teries leading to this area may be 
ligated or separated, or, if the site is 
far enough away from the pylorus to 
avoid the danger of stenosis, a simple 
infolding of this part of the stomach 
wall with sutures results in putting 
this part of the stomach at rest out of 
the range of peristalsis, with a ten¬ 
dency to cure of the ulcer. 

Even a chronic ulcer thrown out of 
the range of peristalsis by infolding 
of the stomach wall may sometimes 
go on to cure, but in the latter class 
of cases it is usually best to excise 
and to perform a gastroenterostomy. 
If the pancreas is involved in an 
operation for ulcer of the stomach, 
any escape of pancreatic secretion 
may cause local necrosis of tissues. 
Where the pyloric portion of the 
stomach is much scarred from old 
ulceration, or engaged in active 
ulceration, complete excision of this 
part of the stomach followed by some 
form of intestinal anastomosis is 
called for. Ulcer of the stomach at a 
distance from the pylorus causes some- 


42 


ABDOMEN, SURGERY OF (MORRIS). 


times hour-glass stomach through 
contraction* of its scars, and the oper¬ 
ation for this condition is referred to 
elsewhere. 

Gastroenterostomy is a satisfactory 
operation in duodenal ulcer, especially 
if supplemented by Enriquez’s sphinc- 
terectomy, which eliminates pyloro- 
spasm and establishes pyloric exclu¬ 
sion. In gastric ulcer the author for 
the last 8 years has been resecting, 
along with the ulcer, the pylorus and 
a variable additional mass of tissue. 
Such an operation alone gives com¬ 
plete and lasting results. Among 217 
gastrectomies the mortality was 
nearly 10 per cent., but in some of 
these there had been grave hemor¬ 
rhage, suppurative perigastritis, or in¬ 
volvement of the liver or pancreas. 
After the resection a posterior gastro¬ 
enterostomy is added. Where neigh¬ 
boring organs have been eaten into 
by the ulcer the cavity is painted 
with iodine. In very weak patients, 
with the lesion near the pylorus, the 
operation is done in 2 stages—first a 
gastroenterostomy, and, 3 or 4 weeks 
later, the secondary gastrectomy. In 
spite of 'Postoperative recovery of 
perfect digestive functions, the patient 
must continue to observe a careful 
dietary. Victor Pauchet (Bull, de 
I’Acad. de Med., Dec. 18, 1917). 

Among 863 cases of gastric ulcer 
dealt with at the Mayo Clinic, opera¬ 
tive mortality was somewhat over 3 
per cent., and 8 per cent, had gross 
hemorrhages after operation. The 
other symptoms were almost always 
completely relieved by gastroenter¬ 
ostomy, but not the bleeding. Ex¬ 
cision combined with gastroenter¬ 
ostomy gave the desired protection 
against hemorrhage. The actual cau¬ 
tery is the safest and surest method 
of removing the ulcer .in most in¬ 
stances. Balfour (Amer. Med. Assoc.; 
N. Y. Med. Jour., June 28, 1919). 

From Jan. 1, 1906, to Jan. 1, 1920, 
1191 patients were operated on in the 
Mayo Clinic for gastric ulcer, 4532 
for duodenal ulcer, and in 203 ulcers 
were found in both regions. 


Gastroenterostomy gives a high 
percentage of cure, but it should not 
be made without positive evidence of 
ulcer. Ulcer of the stomach may be¬ 
come malignant; ulcer of the duo¬ 
denum does not. The operation pre¬ 
ferred in the Clinic is excision or cau¬ 
tery destruction of ulcer of the stom¬ 
ach and destruction of all duodenal 
ulcers that cause hemorrhage. Gastro- 
jejunal ulcers, while rare, may be 
avoided largely by the use of absorb¬ 
able suture material. Sleeve resection 
is recommended in hour-glass con¬ 
tractions of the stomach from ulcer, 
with excision of the lower portion in 
the rare cases of recurrence. In ex¬ 
tensive ulceration and thickening of 
the pyloric region resection of the 
involved lower third of the stomach 
with anterior gastrojejunostomy and 
end-to-side attachment is advised. C. 
H. Mayo (Trans. Miss. Valley Med. 
Assoc.; Med. Rec., Dec., 1920). 

In gastric and duodenal ulcers ex¬ 
cision remains the operation of 
choice, but it cannot always be the 
method chosen, much depending on 
the location of the ulcer, its size, the 
degree of involvement of the visceral 
coats, extent of induration, etc. It is 
the writer’s practice, whenever pos¬ 
sible, to excise the ulcer with the 
knife or cautery. When the ulcer has 
not to any great extent impaired the 
mechanism and the motility of the 
stomach, simple excision without 
a posterior gastroenterostomy will suf¬ 
fice. But from the standpoint of 
rationality and cure, i.e., subsequent 
freedom from symptoms, gastro¬ 
enterostomy is indicated in all cases 
that present marked hyperacidity be¬ 
fore operation. J. B. Deaver (Surg., 
Gynec. and Obstet., Feb., 1921). 

The average death rate for the 4- 
year period after operation in patients 
with gastric ulcers was found slightly 
more than 3 times the normal, while 
in patients with duodenal ulcers it 
was, if anything, less than normal. 
Gastric ulcers may give greater dis¬ 
comfort than duodenal ulcers, and be¬ 
cause of the danger of malignant de¬ 
generations, they should be destroyed 


ABDOMEN, SURGERY OF (MORRIS). 


43 


at the time of the operation unless 
the procedure would add unwarranted 
immediate risk. While blocking the 
pylorus has been recommended in 
addition to gastroenterostomy, the 
procedure was unnecessary and is 
now obsolete. C. H. Mayo (Annals 
of Surg., Mar., 1921). 

The author’s record of operated 
cases of gastric ulcer since 1909 is 
given as follows: Gastrectomy, 96 
cases, 2 deaths, or 2.08 per cent; 
gastroenterostomy: posterior, 701; 
anterior, 8; in Y, 13; gastro-enter- 
ostomy in Y with jejunostomy, 14; 
gastroenterostomy in Y with gas¬ 
trostomy, 2; total, 748 cases, 7 deaths, 
0.9 per cent. Excision of gastric or 
duodenal ulcer with or without gas¬ 
troenterostomy, including Balfour’s 
operation, 43 cases, 1 death. Grand 
total of gastric and duodenal ulcers, 
878, 10 deaths, or 1.11 per cent. J. B. 
Moynihan (Med. Rec., May 28, 1921), 

The various resources for giving* 
gastric and pyloric ulcer a chance to 
heal spontaneously without excision 
of the involved area would often be 
preferable, were it not for the fact 
that cancerous degeneration of the 
embryonic blind tubules at old ulcer 
sites is a frequent occurrence. 

An inexperienced operator had 
better attempt a primary anastomosis 
perhaps and risk the cancer. Jejunos¬ 
tomy purely for artificial feeding may 
be done to prolong life in cases where 
the patient is unable to withstand a 
prolonged operation. When the sur¬ 
geon is first summoned after perfora¬ 
tion has occurred, it is not only neces¬ 
sary to expose and suture the opening 
and cleanse the peritoneum, but it is 
often advisable to take advantage of 
the opportunity for performing a 
radical operation, if one is actually 
indicated. This is also the case often¬ 
times in emergency intervention for 
hemorrhage from an ulcer, and in pen¬ 


etrating wounds of the stomach it is 
further necessary to cleanse the peri¬ 
toneal cavity in the vicinity. 

Carcinoma.—The most radical pro¬ 
cedures are indicated only when there 
is some expectation of cure. With 
early recognition and improved tech¬ 
nique the operative mortality is 
slowly diminishing, and operative 
procedures for comfort of the patient, 
rather than for cure within the three- 
year limit, are increasing in propor¬ 
tion. A preliminary laparotomy is 
often required to make a diagnosis of 
operability in cancer. It is often 
advisable to add a gastrotomy, as 
otherwise early malignant disease has 
been overlooked. 

The only operation for radical cure 
is partial gastrectomy with extirpa¬ 
tion of neighboring lymph-nodes. 
Since patients with well-recognized 
cancer of the stomach seldom live 
beyond a year and suffer greatly, 
palliative operations are indicated in 
theory, but it must be remembered 
that the mortality is rather high in 
such intervention. The resulting 
prolongation of life is also so slight 
that in ordinary cases the risk would 
hardly be worth while were it not for 
the considerable mitigation of suffer¬ 
ing. When a palliative operation is 
undertaken, one with a minimum of 
interv^ention is indicated. Jejunos¬ 
tomy is satisfactory; it provides arti¬ 
ficial alimentation and complete rest of 
the stomach. In certain cases a gastro¬ 
enterostomy may be preferable. 

Case of advanced gastric cancer in 
which an exploratory laparotomy ma¬ 
terially improved conditions, though 
the neoplasm was too large for re¬ 
moval. Lenoir and Gardin (Arch, des 
Mai. de I’App. Digestif, June, 1917). 

From 1897 to 1919, 2094 operations 
for cancer of the stomach were per- 


ABDOMEN, SURGERY OF (MORRIS). 


formed at the Mayo Clinic. There 
were 736 resections with a mortality 
of 13.7 per cent.; 746 explorations, 
with 2.9 per cent.; and 612 palliative 
operations, 11.1 per cent. The com¬ 
mon type of operation was the Mi- 
kulicz-Hartmann-Billroth No. 2, of 
which there were 359 with a mor¬ 
tality of 12.5 per cent. There were 
19 of the Billroth No. 1 type with a 5 
per cent, mortality, 28 sleeve resec¬ 
tions and 7 Kocher operations with a 
mortality of 14.2 per cent, each, 115 
posterior Polya operations, 14.7 per 
cent., and 120 anterior Polyas, 13.3 
per cent. The local resections, 12 in 
number, gave the highest mortality, 
25 per cent. For the last 3 years the 
anterior instead of the posterior Polya 
operation has been used. Better after¬ 
results seem to be obtained by turn¬ 
ing the bowel to the right, closing 
the end of the stomach in toward the 
lesser curvature and protecting the 
closed portion by suturing the un¬ 
opened bowel over it. During the 3 
years previous to September, 1917,- 
patients who recovered from the 
operation and were heard from num¬ 
bered 306; 115 (37.6 per cent.) of 
these had 3-year cures. C. H. Mayo 
(Annals of Surg., Ixx, 236, 1919). 

The writer reports an operative 
death rate of 12 to 20 per cent, in his 
300 gastrectomies for malignant tum¬ 
ors. The survivals have varied from 
6 months to 9 years. He deems pes¬ 
simism in regard to gastrectomy for 
cancer unjustified. With half of the 
stomach he removes a large part of 
the omentum, above and below, in a 
single piece. Before the operation 
the teeth are cleaned by a dentist, the 
gums painted with iodine morning 
and night, and the mouth rinsed with 
hydrogen dioxide. The nose is dis¬ 
infected with an antiseptic oil, and 
the patient trained in deep breathing 
through the nose and accustomed to 
the semiseated position. The stomach 
is rinsed out several times during the 
preceding 2 days. If there is pyloric 
obstruction, he gives an alkaline 
water up to 2 or 3 liters (quarts) a 
day by the drop method, by the rec¬ 


tum or by subcutaneous injection in 
the axillae or under the mammae. If 
haste is necessary, intravenous injec¬ 
tions of 30 per cent, glucose solution, 
or, in case of acidosis, 30 per cent, 
sodium bicarbonate solution are 
given, with epinephrin and other stim¬ 
ulants as needed. He operates always 
under local, regional, or spinal anes¬ 
thesia, and keeps up gastric lavage as 
long as there is vomiting, using hot 
saline. Fluid to 3 liters (quarts) a 
day must be supplied in some way, 
and deep breathing 5 or 6 times every 
hour is ordered. V. Pauchet (Jour, 
de Chir., xvi, 129, 1920). 

Congenital Stenosis of Pylorus.— 

Patients with this affection, even 
when severe, have been known to re¬ 
cover under medical treatment, while 
operation for radical cure had, until 
recently, a high mortality, excepting at 
the hands of experts. Einhorn has 
devised an apparatus for dilating the 
constricted pylorus. If medical meas¬ 
ures fail, pylorotomy or gastroenter¬ 
ostomy is indicated early. 

The Webber-Rammstedt operation 
is less dangerous than the posterior 
gastroenterostomy, and produces 
more immediate relief. The abdomen 
is opened through the right rectus 
above the umbilicus. The tumor is 
delivered and while it is held firmly 
between the left thumb and fore¬ 
finger, an incision is made into the 
tumor in the line of the axis of the 
gut, extending the full length of the 
swelling. This incision is carefully 
deepened until the mucous membrane 
begins to bulge into it. With scis¬ 
sors, the muscle is gently separated 
from the mucous membrane and the 
incision stretched open so that the 
membrane is exposed for a width of 
an inch or more. But little surgical 
shock results. Hypodermoclysis of 
100 to 200 c.c of normal saline and 
4 per cent, glucose solution should 
follow the operation; stimulation is 
provided by hypodermic injection of 
adrenalin in 5-minim (0.3 c.c.) doses; 


ABDOMEN, SURGERY OF (MORRIS). 


45 


external heat is applied; until the 
effect of the anesthetic is over the 
baby is kept with head downward, 
then placed semi-upright, to facili¬ 
tate emptying the stomach and eruc¬ 
tation of gas. An hour after opera¬ 
tion, a few drams of water are given; 
an hour later, 3 drams (4 c.c.) of the 
mother’s milk and 1 of water. This 
is repeated at 3-hour intervals. If 
possible, breast milk should be pro¬ 
vided, and normal nursing resumed in 
a week or 10 days. Gallie and Rob¬ 
ertson (Can. I^Ied. Assoc. Jour., vii, 1, 
1917). 

About 200 cases seen by the writer 
convinced him that the treatment 
was operative. In 100 cases in which 
vomiting had not lasted over 4 weeks 
the mortality was 40 per cent., while 
in those in whom the vomiting had 
lasted over 4 weeks it was 50 per 
cent. This showed very clearly that 
the chances from operation are very 
much better if the operation was 
performed early. While the risk of 
operation is something to be con¬ 
sidered, the risk of not operating is 
greater than the risk of operation. 
Hemorrhage occurred in very few 
cases. In his last 50 or 75 cases 
there had not been a serious com¬ 
plication. Food was given imme¬ 
diately after the child came out of 
the anesthetic, and the amount grad¬ 
ually increased until at the end of 48 
hours it was getting 1 ounce of 
breast-milk at a feeding. At the end 
of a week the child was getting 2 
ounces, but the child was never put 
on the breast pure until 9 or 10 days 
after the operation. The after treat¬ 
ment of these cases is much more 
difficult than the operation. L. Em¬ 
mett Holt (Trans. Amer. Pediat. 
Soc.; N.Y. Med. Jour., Sept. 28, 1918). 

In reporting 5 successful cases by 
the Rammstedt operation, the writers 
urge that breast milk must be given, 
feeding being begun 2 hours after the 
anesthesia has disappeared. They 
give 3 c.c. of breast milk and 3 c.c. of 
barley water, increasing gradually 
until 30 c.c. of breast-milk are given 
every 3 hours during the day and 


every 4 hours during the night. Breast 
nursing is only permitted 5 to 7 days 
after operation. Green and Sidbury 
(Surg., Gynec. and Obstet., Feb., 1919). 

The writer regards as surgical all 
cases in which the symptoms indicate 
complete or incomplete obstruction of 
such a degree that not sufficient nour¬ 
ishment can pass to maintain nutri¬ 
tional balance. The symptoms are 
continuous depression of the weight 
curve, non-fecal or slightly fecal 
stools of small bulk, and continuous 
and severe propulsive vomiting. The 
surgical treatment is posterior gastro¬ 
enterostomy, Rammstedt’s operation 
and Strauss’ operation. The latter has 
the simplicity of Rammstedt’s method 
and also reconstructs the pyloric 
muscle. 

The non-surgical cases are those 
in which sufficient nourishment passes 
to maintain the nutritional balance at 
least for a more or less extended 
period and those in which there is 
but slight loss in weight and it shows 
alternate losses and gains though its 
general trend is horizontal. 

Medical treatment is usually di¬ 
rected to control the vomiting. Breast 
feeding or highly alkalinized artificial 
food should be given, with stomach 
washing once or twice a day with 
warm bicarbonate of soda solution. 
Bromides are all that medicinal treat¬ 
ment has to offer. H. Lowenburg 
(Penna. Med. Jour., xxii, 712, 1919). 

Analysis of 163 cases in which the 
Rammstedt operation was performed. 
Of these, 131 children recovered and 
32 died, a mortality of 19.63 per cent. 
In all cases except the 7 in which 
death was due to complications, the 
fatal result could definitely be attrib¬ 
uted to a state of inanition existing 
at the time of operation. The mor¬ 
tality in artificially fed babies is more 
than 3 times that for the breast-fed 
babies. Goldbloom and Spence (Amer. 
Jour. Dis. of Children, Apr., 1920). 

Early surgical treatment is indi¬ 
cated in all cases. Rammstedt’s oper¬ 
ation appears to be the only pro¬ 
cedure which restores the pylorus to 
a condition approaching normal. The 


46 


ABDOMEN, SURGERY OF (MORRIS). 


general practitioner accustomed to 
surgical technic can successfully per¬ 
form this operation, even in the most 
severe cases. MacDonald (Lancet, 
Feb. 26, 1921). 

Hour-glass Stomach.—This condi¬ 
tion is considered by some under the 
results of gastric ulcer, its usual 
causation. When it is discovered by 
exploratory laparotomy, or, better, with 
the fluoroscope, gastroplasty or gas- 
trogastrostomy may be indicated, the 
former for enlarging the diameter of 
the constricted portion, and the latter 
for establishing a new communication 
between the stomach pouches when the 
first-named intervention is impracti¬ 
cable. Since some operators perform 
a secondary gastroenterostomy in such 
cases to avert the necessity for a pos¬ 
sible second operation, it becomes a 
question whether a primary anastomo¬ 
sis is not the indication of choice. The 
latter in any case may be made with 
one or both stomach pouches, accord¬ 
ing to circumstances. 

Gastroplasty is suitable only for 
cases in which the pouches are mov¬ 
able, their walls free from induration, 
and the constricted area narrow. 
Gastrostomy is especially adapted 
where the stomach is adherent along 
its lesser curvature to the liver, in 
which the pouches are relatively 
large, nearly equal in size, and can 
be approximated at their dependent 
portions. Mediogastric resection or 
resection in continuity is the ideal 
operation provided the pylorus is not 
stenosed, and should be performed in 
all suitable cases. Unfortunately, it 
is limited to the cases with few ad¬ 
hesions in which the pouches are 
fairly large, and permit of free mob¬ 
ilization. Midgastric resection per¬ 
formed by the author in 5 cases; in 
3 a perfect result seemed to have 
been obtained, all symptoms having 
disappeared. W. A. Downes (Surg., 
Gynec. and Obstet, Jan., 1918). 


Non-obstructive or Atonic Dilata¬ 
tion.—Atonic dilatation of the stom¬ 
ach or gastric myasthenia, like 
pylorospasm and relaxation of the 
pylorus, is only a symptom of some¬ 
thing else which needs to be worked 
out before we consider any operative 
work, but when the patient is losing 
ground in spite of other treatment, 
and we have pyloric obstruction due 
to kinking, a gastrojejunostomy or 
Finney’s operation will make the 
work of the physician easier. Fin¬ 
ney’s operation is preferable in cases 
in which the gastric motility is. not 
much impaired. Gastric adhesions 
involving the stomach lessen the 
movements of the muscularis of the 
stomach, disturb circulation, and pro¬ 
duce disturbances which predispose 
to ulceration, and a simple separa¬ 
tion of these adhesions in some cases 
of chronic ulcer of the stomach 
or pylorospasm or relaxed pylorus 
obviates need of other treatment. 

The operation of gastroplication, 
however, is usually performed for 
non-obstructive or atonic dilatation, 
with or without a secondary gastro¬ 
enterostomy ; but there are very 
many cases of atonic dilatation which 
do not properly belong to surgery at 
all, and we must look for these con¬ 
ditions as reflex from some peripheral 
irritation, or some central nervous 
derangement. Atonic dilatation may 
result from exhaustion of the mus¬ 
cularis due to persistent attempts for 
years at overcoming partial obstruc¬ 
tion at the pylorus, due to the pres¬ 
ence of adhesions or ulcer scars. It 
may be due to the influence of distant 
peripheral irritation, such as loose 
kidney or eye-strain, or to fibroid de¬ 
generation of the appendix. 


ABDOMEN, SURGERY OF (MORRIS). 


47 


All these possible factors must be 
very carefully excluded one by one, 
and all three are at the present day 
generally overlooked by diagnosti 
cians. Atonic dilatation occurring 
with certain psychoses, while belong¬ 
ing in the medical class, may never¬ 
theless sometimes warrant surgical 
intervention. 

Gastroptosis.—The operation of 
gastropexy or omentoplication for 
shortening the suspensory (gastro- 
hepatic) ligaments of the stomach is 
indicated in this condition, if the 
gastroptosis occurs singly, but it is 
apt to be associated with panptosis, 
due to relaxation of peritoneal sup¬ 
ports of intra-abdominal organs; so 
that at the same time we usually 
need to shorten the suspensory liga¬ 
ment of the liver, repair a diastasis 
of the rectus muscles, and perhaps fix 
loose kidneys in place. This severe 
operation makes it advisable to ac¬ 
complish all that is possible with 
external supports before resorting to 
operative procedures. Most of the pa¬ 
tients with visceral ptoses are neuras¬ 
thenics, and surgery is of temporary 
avail only,—to be avoided if possible. 

Gastroplication, or shortening the 
lesser omentum, gives good results at 
first, but then the omentum stretches 
and the previous condition returns. 
Gastroenterostomy is absolutely con¬ 
traindicated in gastroptosis. Gas¬ 
tropexy in 62 cases was applied by 
the writer, who reports 67.7 per cent, 
cured and 20.9 per cent, improved. 
Only 9.6 per cent, failed to derive 
benefit, aside from 1.6 per cent, who 
died. In 42 re-examined recently 
after over a year or more, only 4.1 
per cent, were not improved or cured, 
outside of 2.6 per cent, who had died. 
In 6 cases he fastened the liver in 
place' at the same time. When 
spasm of the pylorus was part of the 
clinical picture, he slit the pylorus 


lengthwise and sutured the lips to¬ 
gether crosswise, with complete suc¬ 
cess in 11 cases. 

In gastropexy Rovsing draws the 
stomach out through a median in¬ 
cision and makes an interrupted 
suture in the serosa, parallel to the 
lesser curvature, and reaching up 
close to the pylorus. Then, parallel 
to this, other rows of sutures are 
taken at intervals of 2 cm. The ends 
of the sutures are brought out 
through the abdominal wall to the 
left. The abdominal incision is then 
sutured and closed with collodion, 
and the ends of the suture material 
tied over a glass plate covered with 
gauze. The author’s modification 
consists in carrying the suture ma¬ 
terial around the right costal arch or 
directly under it through the skin. 
The ends of the threads are brought 
out 4 to 3 cm. from their entering 
points and tied over glass drains 
wrapped in gauze. The stomach is 
fastened in its proper place and 
shortened in length at the same 
time. E. Bircher (Correspond.-blatt 
f. Schweizer Aerzte, Mar. 31, 1917). 

Foreign Bodies.—Gastrotomy for 
the removal of foreign bodies is occa¬ 
sionally indicated, and does not differ 
from ordinary exploratory gastrot¬ 
omy, excepting that the incision may 
be made very small in some cases, 
and just large enough to allow the 
entrance of forceps, which may be 
guided to the object through the aid 
of the fluoroscopic screen. This 
IMter resource may also be used for 
reaching small objects in any part of 
the intestinal tract. 

Stricture of the Esophagus.—Gas¬ 
trostomy is required for some cases 
of stricture of the esophagus, to 
furnish access from two directions 
for dilatation purposes. 

TYPICAL OPERATIONS UPON 
THE STOMACH.—Gastroplication. 
—This operation, which is intended 


48 


ABDOMEN, SURGERY OF (MORRIS). 


to reduce the size of the stomach by 
infolding its anterior wall, has been 
done successfully for simple non¬ 
obstructive dilatation, as well as for 
cases of pyloric obstruction due to 
the presence of bile-tract adhesions or 
ulcer scars. In several cases in which 
gastroplication seemed to be indi¬ 
cated because of dilatation secondary 
to the presence of adhesions, a simple 
separation of such adhesions, together 
with gastric lavage and massage subse¬ 
quently, has allowed the stomach to re¬ 
gain its normal dimensions. 

The principle of the operation 
involves the introduction of sutures 
placed within the seromuscular tissue. 
The more numerous and the longer 
the sutures, the greater the reduction 
in the capacity of the organ. The 
interrupted sutures are inserted at 
the lesser curvature, and passed in 
and out at intervals of one inch apart, 
until the anterior wall has been 
traversed without tying any sutures. 
They should be parallel in their 
course; the end sutures must not be 
placed so as to be in danger of con¬ 
stricting the lumina of the esophageal 
or pyloric orifices. 

The sutures should be tied only 
when all have been placed in a row 
ready for knotting. If one suture 
were to be knotted in advance of, i.e., 
before, the introduction of the next 
one, it would run the operator along 
in an undesirable plane, for mechani¬ 
cal reasons evident while one is 
operating. The anterior wall will 
be puckered, creased or reefed ac¬ 
cording to the technique used, with 
resulting restoration of the natural 
capacity of the stomach. The sutures 
may be inserted in series of super¬ 
imposed planes when the dilatation 
is excessive. 


After gastroplication a cross-sec¬ 
tion of the organ shows a series of 
plaits if one plane of sutures is used; 
while, if several planes are super¬ 
posed, a sort of diaphragm projects 
across the cavity. These formations 
tend to undergo some atrophy. 
Although the normal size of the 
organ is restored, the shape is not, 
and the tendency of the posterior 
wall to pouch must sometimes be 
oflfset by a posterior gastroenteros¬ 
tomy. It has even been counselled to 
perform the latter as a matter of 
routine. 

A form of gastroplication has also 
been performed for gastric ulcer. The 
reef of the stomach wall which is the 
seat of the lesion is thus placed in 
relative rest, and under appropriate 
medical measures the ulcer may dis¬ 
appear during the atrophy. Two 
suture points usually suffice. Natu¬ 
rally the operation is best suited to 
ulcer of the anterior wall. 

Gastric Omentoplication.—Gastric 
omentoplication may be mentioned in 
this connection. This operation con¬ 
sists in taking a tuck in the suspen¬ 
sory ligaments of the stomach, and is 
indicated in gastroptosis. These por¬ 
tions of the lesser omentum known 
respectively as the gastrohepatic and 
gastrosplenic ligaments are sutured 
in three superposed planes with 
mattress sutures, the deepest being 
inserted for a very short distance, 
one-half inch to one inch near the 
pylorus. The next plane projects 
well beyond the confines of the first, 
while the third corresponds to the 
amplitude of the tuck to be made. 
The sutures are then tied in the order 
of^ insertion. It must be .borne in 
mind that the aim of omentoplica¬ 
tion is to secure elevation without 


ABDOMEN, SURGERY OF (MORRIS). 


49 


compromising the mobility of the 
stomach. 

Gastrotomy.—Incision of the stom¬ 
ach is indicated primarily for explora¬ 
tion of the stomach, and at the same 
time when required for the removal 
of foreign bodies, tumors, etc., check¬ 
ing hemorrhage, and dilating stric¬ 
tures at either orifice. It is always 
desirable after the laparotomy incision 
to examine the stomach thoroughly 
frorn without before incising its wall. 
The technique for incising the stom¬ 
ach is practically the same in different 
operations, although the site and ex¬ 
tent may vary with the condition to 
be treated. The usual incision is 
made in the long diameter as far as 
possible from large blood-vessels, and 
is not less than three or more than 
five inches long. It is advisable to 
wash out the stomach before opera¬ 
tion, but when this for any reason has 
not been done the organ must be 
evacuated by sponging gently with 
gauze or flushing with a siphon. 
Before incision the stomach must 
have been walled oflf from the peri¬ 
toneal cavity with gauze. After the 
purpose of the operation has been ful¬ 
filled, the gastric incision is closed 
with one or more planes of con¬ 
tinuous silk or linen sutures of the 
Lembert type. 

When gastric ulcer is present some 
additions to the technique may be 
required. When the operation has 
been undertaken for hemorrhage 
from the ulcer, the latter must, if 
possible, be excised, and if an ulcer 
is found it is always best excised 
irrespective of the question of hemor¬ 
rhage. It may, however, be impracti¬ 
cable to excise, from the position of 
the ulcer, or because of multiple 
ulcers or bleeding points, or the 

1—4 


source of the hemorrhage may be 
obscure. Under such circumstances 
hemostatic procedures may be un¬ 
available, and may even aggravate 
the state of affairs. The only resource 
in such cases is to perform gastro¬ 
jejunostomy. Whenever an ulcer can 
be excised, the wound is closed first 
with catgut sutures, and a Lembert 
silk or linen serous suture must be 
superposed. 

When the ulcer is seated on the 
posterior wall with implication of the 
serous coat, it can hardly be dealt 
with through the anterior incision, 
and therefore an incision must be 
made through the transverse meso¬ 
colon, and the posterior wall of the 
stomach brought into view. When 
the pylorus is the seat of the ulcer, 
simple excision will be inadvisable 
because of subsequent stenosis, and 
pyloroplasty will be indicated. When 
there is, besides, any evidence of esoph¬ 
ageal stricture, great care should be 
taken to perform gastrostomy by a typ¬ 
ical method, unless there is a possibil¬ 
ity that the obstruction can be relieved 
and the treatment completed from 
above. It would be impracticable to 
turn an ordinary gastrotomy incision 
into a gastrostomy fistula. 

Pyloroplasty (Heinecke - Mikulicz 
Operation).—This operation consists 
in restoring the original caliber of the 
pylorus when it is the seat of a simple 
stricture, or when suture following 
excision of an ulcer would result in 
pyloric stenosis. As cicatricial stric¬ 
ture of this orifice is due usually to 
the healing of ulcers, the operation is 
practically associated with this condi¬ 
tion. Only a single procedure known 
as the Heinecke-Mikulicz operation is 
current in the narrower sense of the 
word, as other operations to which 


50 


ABDOMEN, SURGERY OF (MORRIS). 


the name is given are in part gastro- 
duodenostomies. 

The technique is as follows: The 
stomach having been exposed by a 
median incision, the pylorus is drawn 
out, walled off from the peritoneal 
cavity, and incised. The presence of 
adhesions renders this stage difficult 
and sometimes furnishes a contrain¬ 
dication. The incision may be made 
after an assistant has approximated 
the stomach and duodenum, each at 
a point some three inches beyond the 
stricture. The incision while made 
in the long axis of the pyloric end, 
extending from duodenum to stom¬ 
ach, is really made from following 
the pyloric curve, of a horseshoe 
shape. Any redundant tissue is ex¬ 
cised. If a fresh ulcer is present most 
authors prefer to do a gastroduo- 
denostomy. In order now to enlarge 
the pyloric lumen, forceps applied to 
the middle of each lip of the wound 
are made to pull it into a straight 
transverse incision. In this position 
it is sutured in two planes including 
the peritoneal layer, unusual care 
being required because the incision is 
not sutured in its original plane. 

Despite the recommendations of 
Mikulicz and other eminent surgeons, 
the operation has many drawbacks. 
Adhesions are likely to result, and 
whether from this or other causes the 
stenosis may reappear. The indica¬ 
tions therefore are, as a rule, better 
carried out by performing some form 
of gastroduodenostomy or pylorec- 
tomy. 

Pyloroplasty by Finney’s (Gould’s) 
Method and Gastroduodenostomy.— 
In both of these procedures an anas¬ 
tomosis is made between the stomach 
and duodenum, but the objects are 
entirely unlike, being in Finney’s 


operation the widening of a stenosed 
pyloric orifice, while in the latter the 
pylorus is excluded outright by a 
short circuit. Gastroduodenostomy 
does not differ essentially from gas¬ 
troenterostomy in general save that 
the duodenum must be mobilized 
beforehand. As that step is also 
required in Finney’s pyloroplasty, the 
latter alone needs a detailed descrip¬ 
tion. 

The operative success will be due 
to the mobility of the duodenum, 
which may be and usually is more or 
less immobilized by secondary adhe¬ 
sions, and to such extent sometimes 
as to appear inoperable. Aside from 
adhesions the anatomic relations may 
be such as to require considerable 
operative manipulation to make the 
parts accessible, sometimes division of 
gastric ligaments. Traction sutures 
may then be inserted outside of the 
area to be incised for the purpose of 
steadying and tightening the tissue, 
but here it is better to use clamps, as 
in Gould’s modified operation, which 
brings pyloroplasty in the same class 
as other anastomoses. The clamps 
grasp the duodenum and stomach in 
the long diameter—not in the trans¬ 
verse diameter, which would be the 
case in an exclusion of short-circuit 
anastomosis—with one clamp secur¬ 
ing the duodenum and the other 
the stomach just above the greater 
curvature; the two are brought side 
by side and the two portions of 
intestine united by continuous sero¬ 
muscular sutures. A U-shaped inci¬ 
sion is now made, the bend of 
which corresponds to the pylorus. 
Redundant mucous membrane is 
clipped off; the resulting diaphragm 
or tongue is overcast with a second 
row of continuous sutures, simple 


ABDOMEN, SURGERY OF (MORRIS). 


51 


communication now being* established 
between the duodenum and stomach 
at the natural orifice. An elliptic 
space remains to be closed with two 
planes of sutures, one all-embracing 
and the other serous and muscular. 

Gastrostomy. — Hacker's Operation. 
—This procedure is rather a small 
gastrotomy left unsutured than a 
true gastrostomy, in the modern 
sense of the term. It is recommended 
chiefly in emergencies. The stomach 
having been exposed and temporary 
traction sutures passed through its 
wall to steady the organ, two planes 
of permanent sutures are inserted on 
either edge of the wound. The first 
plane passes through the abdominal 
wall only, including the peritoneum; 
the second, placed just within the 
others, includes in its grasp the walls 
of the stomach, but without entering 
the cavity. The sutures are then tied 
and cut close, so that the stomach is 
fixed to the abdominal wall. Addi¬ 
tional smaller sutures are left in place, 
and the wound packed with gauze. 

At a subsequent period, usually 
the following day or the second day, 
the wall of the stomach is opened 
with a knife, the wound being one- 
half inch long or just the size to 
contain a tube which should fit 
closely. The traction sutures should 
now be withdrawn. The abdominal 
incision for this operation should be 
three inches long and vertical in 
direction, slightly over an inch to the 
left of the linea alba, and beginning 
about one inch beneath the costal 
arch. When the rectus muscle is 
exposed the anterior fascia is divided 
with the scissors, but the belly of the 
muscle is separated bluntly. The 
posterior layer of the sheath is again 
divided with the scissors, exposing 


the peritoneum. This is opened only 
sufficiently to admit the finger, but 
subsequently prolonged with blunt 
scissors, and the peritoneum and 
muscle sutured with catgut. 

Franck's operation is a so-called 
valve operation, in which the portion 
of stomach wall to be incised is 
passed out of a relatively large orifice 
under a bridge of skin, and finally out 
of a smaller incision, in which local¬ 
ity it is incised. 

The layer incision is known as 
Fenger’s and runs parallel to the 
costal arch and about one inch below 
the latter, starting to the left of the 
ensiform cartilage and not exceeding 
two inches in length. When the 
parietal peritoneum is divided it is 
sutured to the muscles of the abdom¬ 
inal wall. With two fingers in this 
opening the anterior wall of the 
stomach is drawn out and the apex 
of the resulting cone transfixed with 
a traction suture, while a running 
silk suture unites the base of the 
cone to the edges of the wound, all 
the tissues being embraced except the 
skin and the gastric mucosa. 

The lesser incision is parallel to the 
first and seated an inch above the 
margin of the costal arch. Its length 
should not exceed one inch. The 
tissues between the two incisions are 
then detached from the subcutaneous 
structures, when with the aid of the 
traction suture the apex of the cone 
is drawn under the bridge of skin and 
out of the lesser opening, to the edges 
of which it is sutured. The major 
orifice is then closed and the apex of 
the stomach cone opened, a tube 
being placed within the canal. The 
Fenger incision may be replaced by 
a vertical one, as advised by Robson 
and others. 


52 


ABDOMEN, SURGERY OF (MORRIS). 


Witsel's Operation. — The canal, 
which acts as a valve, passes ob¬ 
liquely through the wall of the stom¬ 
ach. The anterior surface of the latter 
is exposed in the usual manner and 
sutured to the wound; an opening is 
then made in the central portion, 
toward the greater curvature. Into 
this a soft catheter is passed; the 
portion outside the stomach is laid 
flat against the latter, and directed 
downward and outward. 

Sutures are now passed through 
the seromuscular coats of the stomach 
over the tube and through the oppo¬ 
site side so that when tightened the 
tube is covered by a fold of stomach 
wall. The first suture point is seated 
one inch from the opening in the 
^ stomach and the entire length of the 
canal should be about an inch and a 
half. The abdominal wound is closed 
down on the free end of the tube, 
which is left projecting. 

Kader*s Operation .—The tube enters 
the stomach directly instead of ob¬ 
liquely, and the canal is formed by 
producing an artificial thickening of 
the stomach with certain planes of 
suturing. Thus with the tube in situ, 
two folds of stomach wall are formed 
by inserting sutures twice through 
the wall—one to each side of the 
tube. These are tightened and cut 
close, and similar sutures are next 
inserted just outside the first. Each 
plane comprises four sutures. The 
canal thus produced is about half an 
inch long and has a good valvular 
action. 

A similar canal may be produced 
by several planes of purse-string 
sutures, as recommended by the late 
Dr. Senn. 

Author's Operation .—The author 
constructs a fistula lined with epithe¬ 


lium:, by utilizing long skin flaps. At 
the left costal border, over the chosen 
stomach region, make an incision five 
inches long through the skin and sub¬ 
cutaneous tissues directly cephalad 
from the costal border. Make a simi¬ 
lar incision on either side of the first 
incision, giving two ribbons of skin 
each one inch in width. A transverse 
incision at the cephalad end of the par¬ 
allel incisions frees the ends of the 

skin ribbons. The skin ribbons are 

next freed throughout their length, 
but remain attached at the costal bor¬ 
der. The epithelial surfaces of the 

skin ribbons are placed in apposition 
and a running suture of catgut unites 
their margins. This transforms the 

ribbons into a tube of skin. The stom¬ 
ach is exposed and opened. The free 
end of skin tube is sutured with silk to 
the mucosa of the stomach. A rubber 
tube is passed through the skin tube. 
One end of the rubber tube is to re¬ 
main in the lumen of the stomach un¬ 
til repair of the wound is complete. 
The other end of the rubber tube 
emerges from the skin tube on the ab¬ 
dominal wall, and serves for introduc¬ 
ing nourishment. When the skin tube 
with its contained rubber tube follows 
the stomach into place, the remaining 
structures to be sutured have fallen to¬ 
gether in such a way that the character 
of final suturing is apparent, and needs 
no description. After repair of the 
wound is sufficient, at the end of a few 
days, the rubber tube is removed. This 
leaves a fistula lined with epithelium 
extending between abdominal skin and 
stomach mucosa. The stomach has 
drawn the skin tube into position at 
such an angle that atmospheric pres¬ 
sure keeps the skin tube closed, except¬ 
ing at times when food is to be intro¬ 
duced. 


ABDOMEN, SURGERY OF (MORRIS). 


53 


Ga s tr o rrh aphy . — The operation 
comprises working beyond an emer¬ 
gency suture of the stomach wall for 
traumatisms, the latter including 
perforation from gastric ulcer. But 
since gastrorrhaphy is involved in 
suturing a gastrotomy wound there 
is little to be said under a special 
heading beyond the statement that 
some modifications arise from the 
nature of the injury. The technique 
of closing stomach wounds is des¬ 
cribed with gastrotomy. 

Description of a method of per¬ 
forming gastrostomy which prevents 
discharge of food from the stomach 
through the opening. Through a 
median incision the anterior wall ot 
the stomach is seized near the cardia. 
The resulting cone is drawn through 
a tunnel made for it in a narrow strip 
of the rectus muscle, to the right of 
the median incision. The cone is then 
drawn farther toward the right, 
through a second tunnel 2 cm. be¬ 
yond the first, the whole slanting up¬ 
ward and outward, and the tip of the 
cone is fastened in the upper portion 
of the last one of the three incisions 
in the skin. The stomach is fastened 
to the rectus muscle close to the first 
incision, and also to the strips of rec¬ 
tus muscles bridging it as the cone 
is drawn up toward the right to hold 
the whole in place. The protruding 
cone can be opened at once or later; 
the two small incisions are sutured at 
once. There is no danger of the 
sphincter thus made becoming dis¬ 
placed or twisted, and the fistula is 
continent in all positions. Solid food, 
finely chopped, can be given almost 
from the first. D’Agostino (Arch, 
ital. di Chir., iii, 285, 1921). 

Gastroplasty.—Gastroplasty is a 
procedure which is indicated only in 
hour-glass stomach, and differs but 
slightly from pyloroplasty, the con¬ 
striction of the organ taking the place 
of the pylorus. As in Finney’s 
pyloroplasty, the two portions of the 


stomach are first brought together by 
sutures or clamps and a horseshoe 
incision made around the suture line 
at a distance of one-fourth inch. The 
inner or posterior edge of the wound 
having been stitched by a continuous 
suture, the outer or anterior edge is 
similarlv treated. The communica- 
tion between the two halves of the 
stomach is thereby greatly amplified. 
Re-enforcing sutures will probably 
be required for the anterior sutures. 

Gastroplasty may also be per¬ 
formed along the lines laid down for 
the 1 feinecke-Mikulicz pyloroplasty, 
in which a transverse incision is 
changed to a vertical one. The value 
of the operation is in question. 

The writer carried out the follow¬ 
ing experiments in dogs; He im¬ 
planted a section of the small intes¬ 
tine in place of resected pylorus. 
The fluoroscopic examination proved 
the absolutely good function of the 
implanted intestine and the examina¬ 
tion of the specimen of the dog 
killed after weeks showed remark¬ 
able changes in epithelial structure, 
the epithelium of the jejunum grow¬ 
ing similar to that of the stomach. 
C. Beck (Surg., Gynec. and Obstet., 
Feb., 1915). 

Castrogastrostomy.—Like gastro¬ 
plasty the operation is indicated only 
in hour-glass stomach. It consists of 
a simple anastomosis between the 
halves of the stomach, which then 
possesses two distinct communicating 
passages. The two stomach pouches 
are sutured together with a continu¬ 
ous Lembert silk suture along one 
side. The two pouches are next 
incised, and the cut surfaces joined 
as in gastroenterostomy, and final 
suturing completes the apposition of 
the pouches. 

Partial Gastrectomy.—Partial gas¬ 
trectomy, the name of which is self- 


54 


ABDOMEN, SURGERY OF (MORRIS). 


explanatory, is undertaken chiefly for 
cancer of the pylorus, and to a certain 
extent for cancer of the stomach 
proper, gastric ulcer, and hour-glass 
stomach. When performed for benign 
ulceration the cases selected are those 
near the pylorus when the lesion is 
unusually large, indurated or multi¬ 
ple. When done for hour-glass stom¬ 
ach the constriction between the 
stomach pouches is the seat of an 
ulcer, and the excision can be com¬ 
bined with gastrogastrostomy. 

Technically the mere excision of a 
bleeding ulcer anywhere in the 
stomach is a partial gastrectomy, but 
in the typical operation the pylorus 
must be sacriflced, and therefore the 
continuity of the digestive tube must 
be restored by some form of gastro¬ 
enterostomy, either gastroduodenos- 
tomy by end-to-end anastomosis, a 
gastroduodenostomy by implanting 
the duodenum in the stomach wall, 
or an ordinary gastroenterostomy. 
Partial gastrectomy has been divided 
into a typical and a cylindrical 
method, but the former, which relates 
only to excision of ulcer areas in the 
stomach proper, is sufficiently com¬ 
prehended under gastrotomy. Cylin¬ 
drical gastrotomy is also termed 
pylorectomy, since the pylorus is 
always excised completely, alone or 
with more or less of the entire con¬ 
tinuous gastric wall. Over a third 
of the organ may thus be sacrificed. 

Billroth*s Operatiofi .—The original 
Hiethod practised by this surgeon was 
to excise the pylorus and the neces¬ 
sary portion of the stomach wall, and 
to suture the cut end of the stomach 
until it reached the size of the duo¬ 
denum. The two cut ends were then 
joined by end-to-end anastomosis. 
At a later period the same surgeon 


preferred to close up both cut ends 
and perform a posterior gastrojeju¬ 
nostomy. 

Billroth prefaced his pylorotomy 
by ligating the vessels of the greater 
and lesser curvatures, and next tied 
oflf the peritoneal attachments (gas- 
trohepatic and gastrocolic ligaments). 
This mobilization enables the pylorus 
to be drawn out of the external inci¬ 
sion. Clamps are then applied to 
either side of the pylorus, two pairs 
each to duodenum and stomach, at a 
distance of an inch from the diseased 
area. Fingers or clamps may be used 
on the proximal sides. The stomach 
and then the duodenum are divided 
between the clamps. The divided 
end of the stomach is sutured, after 
complete hemostasis is secured with 
a running suture of chromicized gut, 
passed through-and-through on each 
side in order to secure some inversion. 
The suture is carried from above 
downward to such a distance that the 
unstitched portion corresponds in 
size to the cut surface of the duo¬ 
denum. A second through-and- 
through suture plane is added and 
serves to further invert the wound 
edges. 

The duodenum is not divided until 
the stomach has been sutured. The 
two divided ends are now partly 
joined by a continuous Lembert 
suture, leaving room to apply an in¬ 
folding through-and-through suture 
of chromicized catgut within the 
plane of the outside suture, which 
latter is then completed. 

Kocher*s Operation .—In this method 
the cut end of the stomach is com¬ 
pletely closed while the cut end of 
the duodenum is implanted into the 
posterior wall of the stomach. The 
pylorectomy itself does not differ 


ABDOMEN, SURGERY OF (MORRIS). 


55 


essentially from that of Billroth. 
The divided end of the stomach is 
completely closed by two planes of 
sutures, an inner continuous through- 
and-through suture of chromicized 
gut, and a Lembert suture outside of 
it. The essential part of the opera¬ 
tion consists in the gastroduodenos- 
tomy by which the cut edge of the 
duodenum is implanted about two 
inches behind the closed wound of 
the stomach. The duodenum held in 
position with fingers is first made 
fast to the stomach by a running 
Lembert suture inserted at the point 
of contact with the stomach and 
occupying one-half of the gut just 
back of the cut edge. The stomach 
is then incised just beyond this suture 
line in such manner that the two 
edges may be exactly approximated. 
The anastomosis is now made with a 
continuous interior suture of chromi¬ 
cized gut, and the original outside 
suture is completed. The interior 
anastomosis suture is inserted by 
the through-and-through method, and 
traverses all the coats of the intestine. 

Hartmann s operation differs from 
the preceding in that it includes ex¬ 
tirpation of the lymph-nodes which 
are seated within the gastrohepatic 
ligament. It is therefore only appli¬ 
cable to cancer of the pylorus in a 
more or less advanced but still oper¬ 
able stage. The operation proper and 
its termination by gastroduodenos- 
tomy or gastroenterostomy are not 
different materially from the pre¬ 
ceding. 

Mayors operation is also a radical 
procedure, and involves not only 
extirpation of lymphatics draining 
the pyloric area, but an unusual 
degree of removal* of stomach, includ¬ 
ing all the lesser curvature. The 


stomach is closed entirely, and con¬ 
tinuity restored by any of the meth¬ 
ods in vogue. 

Review of 266 partial gastrectomies 
involving the pyloric end of the stom¬ 
ach performed in the Saint Mary’s 
Hospital, Rochester, between April 
21, 1897, and Jan. 27, 1910. There 
were 34 deaths from the operation, a 
mortality of 12.4 per cent. Some of 
the patients are still living eight years 
after the operation. The writer does 
not believe the pessimism as regards 
this operation to be justified by the 
facts. He calls attention to two im¬ 
portant indications for operation in 
gastric cancer: 1. Food remnants 
found repeatedly in the stomach after 
twelve hours should, when taken in 
connection with the clinical history, 
call for a surgical consultation, which 
in a large majority of cases will lead 
to an exploratory operation. 2. The 
finding of a movable tumor in the 
pyloric end of the stomach cannot be 
overestimated as to its surgical sig¬ 
nificance. Gastric cancer by itself 
does not give, he is convinced, char¬ 
acteristic symptoms during the cur¬ 
able stage. But if it is'situated in the 
pyloric end of the stomach mechan¬ 
ical conditions are early induced 
which afford most valuable informa¬ 
tion. An effort should always be 
made to remove the lymphatic area, 
whether diseased or not. It must be 
removed before the lymphatics are 
infected. Prophylaxis of gastric can¬ 
cer can be aided by the excision of 
calloused gastric ulcers, which are its 
origin in 70 per cent. A typical re¬ 
section necessitates the removal of all 
that part of the stomach lying to the 
right of a line dropped vertically 
from the cardiac orifice, though in 
some cases more of the fundus must 
be removed on account of the direct 
extension of the disease. As a gen¬ 
eral rule, it will be most convenient 
to make the separation of the super¬ 
ior border of the stomach first, be¬ 
ginning the operation by (a) ligation 
of the superior pyloric vessel, (b) the 
gastric, (c) thi left gastroepiploic, (d) 


56 


ABDOMEN, SURGERY OF (MORRIS). 


the gastroduodenal vessels. As each 
vessel is secured, the glandular sep¬ 
aration is effected. In doing the an¬ 
terior gastrojejunostomy he usually 
follows the method of Hartmann, i.e., 
the two-row suture method with 
slight modifications. Generally speak¬ 
ing, the Kocher method of joining the 
jejunum to the stomach is not so 
satisfactory as the Billroth No. 2 
method, i.e., closing both the end of 
the duodenum and the stomach and 
making an independent gastrojejunos¬ 
tomy. When the patient is in good 
condition the operation has an opera¬ 
tive mortality of under 5 per cent. In 
advanced cases, the resection is worth 
the risk, considering the short lease 
of life of patients left without it. W. 
J. Mayo (Jour, Amer. Med. Assoc., 
May 14, 1910). 

In the method of gastrectomy de¬ 
scribed by the writer, a crushing in¬ 
strument consisting of 3 sets of 
blades is used. The crushed tissue is 
cut across. An over-and-over suture 
is used; after removal of the proxi¬ 
mal crusher an invaginating suture, 
beginning at the center and working 
out to the ends, is inserted. The 
distal portion of the stomach is raised 
with one section of crusher on the 
cut end. The duodenum is sectioned 
in one of several ways. A gastro¬ 
enterostomy is finally done in the 
usual manner. T. De Martel (Amer. 
Jour. Surg., xxxv, 227, 1921). 

Complete Gastrectomy.—This oper¬ 
ation, including subtotal gastrectomy, 
is now practicable as a method, and 
has radically cured perhaps a very 
few individuals of cancer, but is 
seldom attempted, the operative mor¬ 
tality being very great and cases suit¬ 
able for such intervention seldom 
recognized in time. Removal of the 
stomach is not a difficult operation at 
all, but search for and removal of 
lymph-nodes must be very thorough. 
The removal is followed by an end- 
to-end anastomosis made between the 
duodenum and esophagus, or the cut 


end of the former may „ closed and 
the esophagus implanted into the 
jejunum. The author has found it 
much easier to do the work if a small 
part of the cardiac end of the stomach 
is allowed to remain. 

SURGICAL DISEASES OF THE 
PERITONEUM.—Septic Peritonitis. 
—This condition being in the great 
majority of cases secondary to some 
suppurative process either within or 
without the peritoneal cavity, the 
treatment cannot be considered inde¬ 
pendently of that of the primary 
condition, which consists fundament¬ 
ally of incision and drainage of or 
removal of the pyogenic focus. The 
conditions likely to give rise to peri¬ 
tonitis are separately mentioned. If 
the focus is outside the peritoneal 
cavity, the latter need not necessarily 
be opened, because the peritoneum 
rapidly guards itself by hyperleuco- 
cytosis after a focus of infection is 
cared for. If the focus is in the peri¬ 
toneal cavity, it may or may not be 
advisable to treat the peritoneum 
actively. If the peritonitis comes 
from an intestinal perforation an 
enterorrhaphy may be required, but 
it is often safer to make temporary 
•drainage, and fistulae following have 
a tendency to close spontaneously. 
Other cases may require excision, as 
when a portion of the gut is gangren¬ 
ous. In many cases, however, posture 
and drainage alone are indicated, and 
any unnecessary handling of the peri¬ 
toneum is to be deprecated. Only 
when drainage cannot offer a pros¬ 
pect of self-limitation of the process 
is a thorough cleansing of the peri¬ 
toneum indicated, and this is best 
accomplished by flushing with hot 
saline solution through short incision, 
and the glass tube. 


ABDOMEN, SURGERY OF (MORRIS). 


57 


The mortality from peritonitis has been 
much reduced by Murphy’s treatment, 
which consists in making a small opening 
in the abdomen, doing such operation at 
the point of origin of the peritonitis as is 
required, the introduction of a large drain¬ 
age-tube into the pelvis, placing the patient 
in a sitting posture of 35 to 40 degrees, 
and the administration of salt solution 
every two hours by rectum. An important 
feature is to avoid handling the intestines 
or peritoneum more than is absolutely 
necessary. 

It was Murphy’s protest against general 
irrigation of the abdomen, showing that 
the higher mortality rested with those 
who used it, that first attracted the atten¬ 
tion of surgeons to R. E. Kelly. His first 
paper dealt with 5 cases (including 1 
typhoid case) without a death, was fol¬ 
lowed in October, 1906, with 28 cases with 
1 death, and up to a later paper included 
48 consecutive cases with only 2 deaths. 
These aVe astounding results when com¬ 
pared with the prior 50 per cent, mortality 
at the Mayo clinic. 

The principles laid down by Murphy 
were: 1. Operate early. 2. Operate 

quickly. Murphy gave ten minutes as the 
average time in which to close the gastric 
or duodenal opening, or to remove the 
offending appendix or tubes. 3. The anes¬ 
thetic must always be ether, if the patient 
can stand it; if not, then a local anesthetic. 
Stiles’s work has shown how dangerous 
chloroform is in acute suppurative condi¬ 
tions, in the production and retention of 
acetone. 4. It is a fatal mistake to mop, 
wash, or handle the intestine. The peri¬ 
toneum is essentially an absorbing surface; 
carmine granules injected into its cavity 
are rapidly absorbed especially in its upper 
half, and conveyed by the lymph-stream 
to the general circulation. Organisms 
similarly do harm by the rapid absorption 
of their toxins in a similar manner. 
Lymph ij protective, and tends to prevent 
this absorption. 5. The Fowler position 
and a suprapubic drain. The object of the 
Fowler position is to allow the discharges 
to gravitate toward the pelvis, and away 
from the danger zone of the diaphragm. 
The patient, as soon as he has recovered 
from the anesthetic, is placed in the sitting 
posture, so that the abdominal cavity is 


vertical in position, and drainage is insti¬ 
tuted by placing a large drain in the pelvis 
through a stab wound above the pubis. 
This drainage-tube is three-fourths to one 
inch in diameter, about eight inches long, 
glass, and goes down to the pouch of 
Douglas in the female, and the rectovesical 
in the male. In this position the tube is 
almost horizontal; and if it is filled with 
fluid, each excursion of the diaphragm will 
pump a small quantity of it out into the 
dressings. The hole is now at the most 
dependent part of the abdominal cavity. 6. 



Proctoclysis or the absorption of large 
quantities of saline by the rectum for the 
first two days after operation. As soon as 
possible after the operation, a tube having 
numerous holes in it and one-half inch in 
diameter is inserted into the rectum for 
about two to three inches. This is con¬ 
nected by means of a rubber tube of the 
same diameter with a container suspended 
from four to twelve inches above the plane 
of the patient’s couch, and the whole is 
filled with warm saline. By means of this 
head of water (it need only be four to six 
inches in height, as a rule) saline gradually 
trickles into the rectum at about the rate 
of three-quarters to one pint an hour. The 
temperature of the saline is kept at 100° F. 



58 


ABDOMEN, SURGERY OF (MORRIS). 


and should never reach 106° F., or it will 
not be retained. Editors. 

Description of a scheme of treat¬ 
ment for peritonitis based on experi¬ 
ence in 13,145 laparotomies. By this 
plan the mortality in all abdominal 
operations was decreased 33^ per 
cent., and in acute appendicitis alone, 
67.6 per cent.: (1) Nitrous oxide- 
oxygen anesthesia. (2) Local anes¬ 
thesia at site of incision. (3) Ac¬ 
curate, clean-cut operation to dimin¬ 
ish both infection and shock. (4) Ade¬ 
quate drainage. (5) Fowler’s position. 
(6) Vast hot packs over the entire 
abdomen, spreading well down over 
the sides. (7) Five per cent, sodium 
bicarbonate with 5 per cent, glucose 
by rectal drip, continued as long as 
it is tolerated. (8) Primary lavage 
of the stomach, repeated only if in¬ 
dicated. (9) From 2500 to 3000 c.c. 
(5 to 6 pints) of physiological so¬ 
dium chloride solution subcutane¬ 
ously every 24 hours until the period 
of danger is past. (10) Morphine 
hypodermically until the respiratory 
rate is reduced to from 10 to 14 per 
minute, and held to this rate until 
danger is past. The morphine is not 
useful in a streptococcus peritonitis. 
G. W. Crile (Jour. Amer. Med. 
Assoc., Nov. 29, 1919). 

According to the writer, advancing 
postabortal peritonitis has a definite 
symptom complex in the presence of 
which drainage is necessary and defi¬ 
nitely lowers the mortality. The 
patient is placed in the high Fowler 
position; one or more icebags are 
applied to the abdomen, and a proc¬ 
toclysis by the Harris method of 
glucose-sodium-bicarbonate solution 
is begun. The pain is relieved by 
routine morphinization, small doses 
being given hypodermically at regu¬ 
lar intervals. If the patient’s resist¬ 
ance is capable of taking care of the 
peritoneal invasion, in from 12 to 20 
hours there will be a definite reces¬ 
sion in the severity of the symptoms 
and a fall in the polymorphonuclear 
percentage. On the other hand, if 
resistance is insufficient, or virulence 
greater than the protective reaction. 


the pulse, temperature and local ab¬ 
dominal symptoms will remain sta¬ 
tionary or increase in severity, and 
the polymorphonuclear percentage 
will rise. A posterior vaginal in¬ 
cision through the fornix will usu¬ 
ally liberate a pint or more of thin, 
flocculent blood-stained serum which 
on culture returns innumerable strep¬ 
tococci. Polak (Amer. Jour. Obstet., 
Oct., 1920). . 

Report of 22 cases of peritonitis 
treated by‘instillations of ether, with 
17 recoveries and 5 deaths. Of the 
former, 9 were in a very desperate 
condition when operated. The author 
believes himself justified in recom¬ 
mending ether treatment. Neudoerfer 
(Zentralbl. f. Chir., xlviii, 2, 1921). 

Twenty-two cases collected from 
literature, among which enterostomy 
seemed to be the decisive factor in 
the recovery in 12 cases. A cone of 
intestine is drawn up, its base sutured 
to the skin, and a thread run around 
it about 2 cm. from the tip. A cath¬ 
eter is then worked into a minute 
opening in the tip and the thread 
drawn tight, fastening the tip of the 
cone to the catheter. The latter is 
then pushed in as far as desired, thus 
invaginating the cone and protecting 
the portion of the intestine fastened 
to the wall from any contact with 
the bowel contents. Aievoli (Riforma 
Medica, Apr. 16, 1921). 

He who operates in a case of acute 
diffusing peritonitis after the first 36 
or 48 hours of the onset of peritoneal 
inflammation, with no evidence of a 
localizing point, is, in the majority of 
cases, not serving the best interests 
of the patient. In the presence of a 
circumscribed peritonitis with a 
definite localizing point of exquisite 
tenderness, due to an acutely in¬ 
flamed, perforating or gangrenous 
appendix, operation can be undertaken 
in the absence of constitutional or 
other contraindications, provided the 
proper technique is observed in safe¬ 
guarding the peritoneum from con¬ 
tamination by the proper disposition 
of gauze packings. Peritonitis the 
result of intestinal obstruction, gas- 


ABDOMEN, SURGERY OF (MORRIS). 


59 


trie, duodenal, gallbladder, intestinal, 
or colonic perforation, should be im¬ 
mediately operated if the condition 
can be recognized, which it usually 
can if the case is seen early. Too 
thorough operation in peritonitis too 
often spells death. In peritonitis it 
is not the inflammation of the peri¬ 
toneum that is fatal, but -the toxins 
absorbed. J. B. Deaver (Trans. Phila. 
Co. Med. Soc.; Med. Rec., Apr. 30, 
1921). 

Tuberculous Peritonitis.—In theory 
the local focus of disease which has 
caused an extension of the process to 
the peritoneum should be excised, 
whether this is in the intestine, Fallo¬ 
pian tube, appendix, or other remov¬ 
able tissues. But this is not always 
practicable, and, furthermore, patients 
often recover under simple laparot¬ 
omy and drainag'e. The author in a 
series of experiments with animals 
some years agfo came to the conclu¬ 
sion that this cure of tuberculosis of 
the peritoneum after opening the peri¬ 
toneal cavity was due to the presence 
of toxins developed from bacteria 
which grew in the culture medium of 
peritoneal exudate exposed by way 
of the drainage-tube. This was in 
fact true, and the cultures of tubercle 
bacilli in test-tubes were instantly 
killed by toxins extracted from such 
fluid and applied to the cultures. 
A later theory, however, and one 
which is borne out by later studies, 
is that the tubercle bacilli are de¬ 
stroyed by phagocytes in the course 
of the intense hyperleucocytosis whichi 
promptly follows opening of the peri¬ 
toneal cavity for any purpose. The 
idea that such hyperleucocytosis 
proves destructive to the tubercle 
bacilli is further substantiated by the 
fact that various substances injected 
into the peritoneal cavity have proved 
effective in the same way, and for the 


•destruction of tubercle bacilli in the 
peritoneum it apparently matters 
little which method for exciting exag¬ 
gerated hyperleucocytosis is chosen, 
so long as we bring about that phe¬ 
nomenon. 

According to A. K. Stone, operation 
should only be undertaken when there is 
some distress from the distention; it is 
better to wait for a period with the pa¬ 
tient at rest and under the same hygienic 
conditions to which any case of pulmonary 
tuberculosis would naturally be subjected, 
namely, rest, fresh air, good food, and, 
later, moderate regulated exercise. If 
after six or eight weeks there is no im¬ 
provement in the symptoms, operation 
should be considered. When once the dis¬ 
ease is arrested, whether by operation or 
hygienic methods of treatment, the pa¬ 
tients must be taught to regulate their 
lives with the same care that they would 
had their disease been located in the lungs. 

Laparotomy alone should not be 
considered a cure, but the disease 
treated in the light of the patho¬ 
logical conditions found in each case. 
Often, when diagnosed early, the 
peritonitis is found to be confined to 
the region of the primary focus, such 
as the appendix, cecum, and Fallopian 
tubes. In such cases removal of the 
entire infected area with its under¬ 
lying organ or organs is the rational 
method of treatment, to be followed 
by energetic hygienic measures and 
the administration of tuberculin. 
Where the disease has become so 
widespread that it cannot be re¬ 
moved surgically, laparotomy is not 
only not indicated, but may hasten the 
fatal issue. O. M. Shere (Colo. Med., 
June, 1917). 

Surgeons are still in disagreement 
as to the operative procedure to be 
followed, whether simple puncture, 
simple laparotomy or laparotomy 
with consecutive peritoneal lavage. 
Cecherelli attributes vast importance 
to lavage. According to the author, 
it may be used in every anatomic 
variety of tuberculous peritonitis, and 
is absolutely indicated in the forms 
in which purulent diffused or circum- 


60 


ABDOMEN, SURGERY OF (MORRIS). 


scribed collections accumulate toxic 
material. Operation is probably in¬ 
dicated in all forms except where the 
tuberculosis involves the lungs or is 
spread to many viscera or where the 
general state does not permit it. 
Ruffo (Riforma Med., June 16, 1917). 

The writer reports cure in 12 out 
of 15 cases and material improve¬ 
ment of the others by operative treat¬ 
ment. Through a median laparotomy 
he paints the whole accessible peri¬ 
toneal surface with official tincture of 
iodine, loosening up adhesions only 
as necessary to reach all the surface. 
The abdominal wall is always sutured 
at once. Stocker (Corresp.-Blatt f. 
schweizer Aerzte, June 23, 1917). 

Disappearance of effusion, when 
present, may be hastened by moder¬ 
ate purgation, diet restriction, and 
ordinary diuretics. X-ray treatment 
has benefited some patients. Lapar¬ 
otomy is indicated in serous effusion 
if, after several weeks of conserva¬ 
tive treatment, satisfactory progress 
has not been made. Nitrous oxide 
oxygen anesthesia should always be 
used. C. A. Vance (Trans. Ky. State 
Med. Assoc.; Jour. Amer. Med. 
Assoc., Nov. 1, 1919). 

In intestinal occlusion due to peri¬ 
toneal tuberculosis, both the occlusion 
and the peritonitis may be treated by 
a laparotomy. An artificial anus is 
necessary only if the patient’s condi¬ 
tion is very poor or if it becomes 
evident that nothing else can be 
done. Aimes (Rev. de chir., Iviii, 177, 
1920). 

The writer deems tuberculous peri¬ 
tonitis very amenable to cure in most 
instances, at least if the abdominal 
condition is the main factor. Nature 
can cure tuberculous peritonitis in 
pure form. 

Mixed infection destroys tissue, 
but added toxins are destructive 
to life as well as to tissue, and 
are more chronic and difficult to treat 
or control. If ascites in tuberculous 
peritonitis adds so enormously to the 
surface area involved in a tuberculous 
process and must be overcome by 
changes in the peritoneum by chang¬ 


ing the exudate from serous to fibrin¬ 
ous and plastic adhesions before cure 
occurs, such surgical treatment as 
will hasten the process is advisable. 
Death or even ill health rarely comes 
from obstruction due to the adhe¬ 
sions. When acute obstruction de¬ 
velops it is due to a single band 
or the hyperplastic variety without 
ascites. 

By removing the focus of disease 
in tuberculous peritonitis, especially 
when such a focus involves a tuber¬ 
culous mucous membrane, a high per¬ 
centage of permanency of cure with 
a very low primary operative mor¬ 
tality is secured. Mayo (Minn. Med., 
Apr., 1921). 

Ascites.—We speak of surgical 
treatment of ascites rather than of 
cirrhosis of the liver in cases of. the 
latter disease, because the operation 
.has probably little influence upon the 
liver itself. Ascites and hydroperi¬ 
toneum from 'whatever cause may be 
relieved temporarily by paracentesis. 

The incidental laparotomy with 
drainage corrects the condition for 
the time being. We have to be par¬ 
ticularly careful to guard the peri¬ 
toneum against infection in many of 
these cases, for the reason that the 
current of lymph is outward from the 
peritoneum, and it becomes exposed 
to various bacteria. When the cur¬ 
rent is inward, as in normal condi¬ 
tions; there is destruction of entering 
bacteria by the action of blood- and 
body- cells. 

Warning against removal of recent 
tuberculous effusions. All patients 
operated on for tuberculous peri¬ 
tonitis within 2 months of its appar¬ 
ent onset have died, in the author’s 
experience with 100 cases.. Only 
effusions from 3 to 5 months old 
should be removed. There follows 
spontaneously a new, curative effu¬ 
sion. This is the view now held by 
many clinicians. Gelpke (Corre- 



Congenital Cysts of the Mesentery. {H. C. Deaver.) 
Annals of Surgery. 



* • 





V ■ 








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4 


» 


« 


I 


\ 








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± m 

f 


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4 




i 


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1 * 


ABDOMEN, SURGERY OF (MORRIS). 


61 


sponcl.-Blatt f. schvveizer Aerzte, Jan. 
12, 1918). 

Omentopexy or the Talma-Drum- 
mond operation has for its aim the 
establishment of adhesions between 
the omentum and parietal peritoneum. 
These adhesions become filled with 
capillary blood-vessels in time, and 
the free network of small new vessels 
constitutes a venous anastomosis 
around the area of obstructed circu¬ 
lation. This work may l)e done by in¬ 
troducing" numerous pinpoint sutures, 
or by pulling the omentum between 
the transversalis fascia and the pos¬ 
terior sheath of the rectus muscle, 
and fixing it there. 

In addition to establishing a new 
circulation by the roundabout way of 
adhesions of the omentum, it is well 
to scarify the cephalad surface of the 
liver and the corresponding perito¬ 
neum of the diaphragm. This may 
be done very rapidly by the use of a 
nailbrush with the bristles cut very 
short. The peritoneum which has 
been denuded of its endothelium in 
this way throws out abundant lymph 
- and makes extensive adhesions, which 
later are filled with new capillaries. 
The operation seldom accomplishes 
the object for which it is intended in 
a satisfactory way, because it is 
commonly used as a last resource 
when changes in the liver have be¬ 
come too far advanced. The opera¬ 
tion performed before ascites has 
become a disturbing feature is some¬ 
times distinctly of value, particularly 
when the omentum is fixed to struc¬ 
tures extra to the peritoneum. 

The benefit of the Talma operation 
for Banti’s disease is due to the lapa¬ 
rotomy and the resulting hyperemia 
rather than to the omentopexy. The 
latter helps, but the hyperemia from 
the laparotomy is the main factor, as 


determined in the course of 10 such 
cases. In operating the writer aims 
to induce hyperemia as much as pos¬ 
sible and to remove all traces of the 
ascites. If the kidneys are function¬ 
ing defectively, absorption of ascitic 
fluid left behind may prove fatal. He 
knows of two such deaths, and warns 
that pronounced kidney disease con¬ 
traindicates the operation, and that in 
all cases the general anesthesia 
should be as slight as possible. 
Bogojawlensky (Zentralbl. f. Chir., 
Feb. 27, 1909).. 

Three cases in which the writer fol¬ 
lowed Ruotle’s method of treating 
chronic ascites with cirrhosis of the 
liver by suturing the peripheral end 
of the saphenous vein, severed 8 cm. 
above its mouth, to the peritoneum 
just above Poupart’s ligament. In the 
first case, a man of 38, the patient is 
well, with no return of ascites after 
the operation a year ago; in this case 
omentopexy, decapsulation of both 
kidneys, and continuous abdominal 
drainage had failed to cure. In the 2 
other cases the ascites was the result 
of pericarditic pseudocirrhosis of the 
liver; here none of the operations 
done, including the Ruotle, gave re¬ 
lief. T. Soyesima (Deut. Zeit. f. 
Chir., April, 1909). 

Case in which the saphenous vein 
was severed and carried up into the 
peritoneal cavity through a sub¬ 
cutaneous tunnel. The condition 
was immeasurably improved, al¬ 
though at first there was much 
edema in legs and lower trunk. 
Toussaint (Gacete de la Acad, de 
Med., Mexico, Jan.-June, 1917). 

See also the article on Ascites in the 
second volume. 

Surgery of the Mesentery and 
Omentum.—Aside from surgical af¬ 
fections which involve the mesentery 
along with the intestines, the former 
suffers from surgical affections pecu¬ 
liar to itself, more especially solid 
tumors and cysts in the omentum 
and mesenteric folds. They do not, 
as a rule, cause acute or complete 


62 


ABDOMEN, SURGERY OF (MORRIS). 


ileus, but cause pressure symptoms, 
and if left alone tend to set up low- 
grade peritonitis and adhesions to 
neighboring viscera. 

These growths should be extirpated 
whenever operable. Cysts with dense 
adhesions and chylous cysts can only 
be managed by drainage. 

SURGICAL DISEASES OF THE 
INTESTINES.—Ileus.—Most of the 
conditions, which require surgical in¬ 
tervention for the intestine, excepting 
traumatisms, are brought about by 
ileus or intestinal obstruction of some 
form. This is not the place to discuss 
the manifold agencies which produce 
obstruction, nor their recognition be¬ 
fore operation. Once acute obstruc¬ 
tion is evident, the surgeon is usually 
obliged to open the abdomen, his course 
afterward depending on the nature of 
the obstruction. In conditions like in¬ 
tussusception, volvulus, intestinal 
hernia, or obstruction adhesions, the 
obstructed loop is released, and steps 
described for the separate conditions 
are taken to prevent a recurrence of 
the trouble. If the mesentery is too 
long, or the intestine too mobile, a 
reef may be taken in the former, or 
the latter may be anchored to the 
abdominal wall or excised. If the 
intestine has become strangulated 
and is gangrenous, enterectomy is 
indicated with secondary anasto¬ 
mosis. If the obstruction is from 
foreign bodies, as with round-worms 
or gall-stones, for instance, the sub¬ 
stance should be worked back to an 
empty portion of intestine, and an 
enterectomy or colectomy for foreign 
bodies performed. If the loop of intes¬ 
tine shows serious changes as a result 
of obstruction, a temporary artificial 
anus may be advisable. Excision is 
seldom required in such cases. In 


cases of acute ileus from any cause 
secondary peritonitis may develop 
and require treatment (see Peritoni¬ 
tis). While acute ileus may result 
from stricture or tumors, such condi¬ 
tions are much more apt to produce 
chronic stenosis, which ultimately ii 
left alone will produce chronic ileus. 
Such cases naturally tend to come 
to operation before ileus develops. 
Benign growths and cysts of the 
mesentery, and similar formations 
which do not compromise the integ¬ 
rity of the intestine may be removed 
without much interference with the 
latter. Tumors of the gut itself 
necessitate excision of the latter with 
secondary anastomosis, or establish¬ 
ment of artificial anus. Tubercu¬ 
lous strictures are treated by entero- 
clusion, or enterostomy for drainage, 
excision being, as a rule, contrain¬ 
dicated. The same is the alternative 
in inoperable carcinoma. 

Surgical relief of obstruction is the 
only final salvation for life, and 
should be instituted early before the 
patient has absorbed a lethal dose of 
poison. The only excuse for the re¬ 
sponsible physician is the refusal of 
patient to accept his advice. An in¬ 
violable law should be to keep every¬ 
thing out of the stomach. Gastric lav¬ 
age should be practised to delay seri¬ 
ous symptoms until operation can be 
done, and the lost body fluids re¬ 
placed by proctoclysis and hypoder- 
moclysis both before and after opera¬ 
tion. Murphy’s method with re¬ 
section of any area of damaged in¬ 
testinal wall is ideal in early cases in 
the hands of a good technician, but 
it takes time and adds shock in 
late cases. The newer method of 
McKenna, of direct surgical drainage 
of the high intestinal area by a quick 
enterostomy high up in the jejunum, 
tides the patient over the crisis of 
acute toxemia. Six or eight weeks 
later, with the patient in good con- 


ABDOMEN, SURGERY OF (MORRIS). 


63 


dition the damaged and obstructed 
area can be resected. J. N. Jackson 
(Mo. State Med. Assoc. Jour., Sept., 
1917). 

After abdominal operations there is 
usually stasis for 24 hours, which acts 
as a protective measure. Enemas are 
given the day after operation. If 
there is no relief, lavage, laxatives, 
hypodermic injections of pituitrin or 
eserine are given during the second 
night and third day. If these do not 
bring relief, it is concluded that the 
obstruction is complete. The patient 
vomits and is toxic. On the evening 
of the third day or the morning of 
the fourth he is taken to the oper¬ 
ating room and the incision opened. 
If there is general peritonitis an en¬ 
terostomy is made without explora¬ 
tion. If there is no peritonitis, ex¬ 
ploration is made and the cause, 
which is usually an adhesion, is re¬ 
moved; then, of course, enterostomy 
is not necessary. If operation is de¬ 
layed until late in the fourth day, 
toxic paresis may complicate the ex¬ 
isting conditions. C. H. Mayo (An¬ 
nals of Surg., Ixvi, 568, 1917). 

In performing enterostomy for 
postoperative obstruction, without an 
anesthetic, a few stitches are re¬ 
moved, the peritoneum opened, and 
the first distended coil of intestine 
which presents seized. Into it a 
purse-string suture of chromic catgut, 
in a circle at least inch in diameter, 
is placed rather deeply. With the 
intestine held up by grasping the 
suture at 3 different points, a hole is 
burnt through the center of the circle 
with the Paquelin cautery, using the 
pointed tip. A rubber tube is then 
immediately passed through. The 
gut being elastic a tube twice the 
size of the opening may be used. 
The purse-string is now tied, invert¬ 
ing the margin. If conditions permit, 
a second purse-string is also intro¬ 
duced. It is a good plan, when pos¬ 
sible, to either stitch omentum about 
the tube or puncture the omentum 
and pass the tube through it. The 
tube is secured from slipping with 
strips of adhesive plaster. J. W. 


Long (Jour. Amer. Med. Assoc., 
Mar. 17, 1917). 

In intestinal obstruction following 
pelvic operations, 3 stages can be 
noted, those of onset, obstruction, 
and toxemia. Pain, distress, and 
vomiting, not relieved by gastric 
lavage or by enemata, are diagnostic 
signs, and if present, operation 
should be performed immediately. 
But often there is a delay of 24 hours 
before operation is done. Anspach 
(N. Y. Med. Jour., June 22, 1918). 

Analysis of 245 consecutive cases 
of intestinal obstruction. Of the 217 
patients operated on, 76 died, a mor¬ 
tality of 36 per cent. The operations 
varied from such simple procedures 
as the untwisting of a volvulus or 
division of a constricting band to re¬ 
section of several feet of gangrenous 
bowel. The results seemed to de¬ 
pend far more on the condition of 
the patient at the time of the opera¬ 
tion, the long time elapsed since onset 
of symptoms of obstruction, and the 
condition of the bowel, than on the 
nature of the surgical operation. Fin¬ 
ney (Surg., Gynec. and Obstet., May, 
1921). 

Volvulus.—Volvulus most often oc¬ 
curs in the pelvic colon, and conse¬ 
quently does not belong" to this group 
of articles, but it may occur in the 
sig-moid or cecal region. In the latter 
case, after untwisting the volvulus 
and separating any peritoneal ad¬ 
hesions, a rectal tube should be 
passed and the poisonous contents of 
the volvulus massaged gently but 
rapidly toward the rectum, provided 
that no gangrene of the volvulus be 
^present. The prevention of recur¬ 
rence by approximation to the an¬ 
terior abdominal wall by Roser’s 
method is uncertain, and the author 
favors complete excision of the part o^ 
the bowel engaged in volvulus, as this 
can readily enough be spared, and an 
end-to-end or lateral anastomosis of 
the remaining segment of bowel ful- 


64 


ABDOMEN, SURGERY OF (MORRIS). 


fills the indication. Volvulus of the 
cecal region occurs 'when there is a 
congenital form of defect giving a 
sort of mesocecum which may be 
quite long. Excision of the cecum 
and intestinal anastomosis are pref¬ 
erable to any attempt at preventing 
the recurrence of twisting of the cecum. 

Volvulus of the small intestine 
occurs most frequently when the coil 
of bowel is caught by an adhesion 
band, and peristaltic progress may 
loop the bowel in such a way as to 
cause torsion. 

In sigmoid volvulus the writer su¬ 
tures together, side to side, the lowest 
parts of the loop just untwisted. The 
opening must be 6 or 8 cm. long. 
The loop above is thus functionally 
excluded, and finally almost shrivels 
away. C. Pochhammer (Zentralbl. f. 
Chir., Feb. 14, 1920). 

The Grekow-Kummell invagination 
method for the radical cure of vol¬ 
vulus of the sigmoid flexure has cer¬ 
tain definite advantages over resec¬ 
tion. It is simple and brief and per¬ 
mits of both total removal of the 
flexure and absolute asepsis. The 
mobilized portion invaginated in the 
rectum sloughs off spontaneously and 
is expelled in a few days. Lange 
(Zentralbl. f. Chir., Oct. 30, 1920). 

Localized paralysis of the bowel 
occurring in typhoid fever may lead 
to this twisting of the bowel upon 
itself, and the twisted part can best 
be excised if the patient’s condition 
allows it. 

Intussusception.—In a child with 
the patient under an anesthetic, an 
intussusception can sometimes be re¬ 
duced by the hands on the abdomen, 
but the last inch is very difficult of 
reduction, and we are likely to do 
damage by persistent efforts. There 
is the same objection to water injec¬ 
tion, as we cannot know whether the 
last inch has been reduced or not. 


Furthermore it is very easy to 
rupture the bowel of a child. We 
may reduce an intussusception better 
through a very short incision, even 
though children bear the operation so 
badly. Perhaps it is best not to apply 
many of the resources for intussus¬ 
ception described in the older text¬ 
books, with the exception of operation 
by immediate laparotomy. There is 
no occasion in this article to describe 
the many varieties of intussusception, 
because the principles of treatment 
are practically the same in all. Re¬ 
duction of intussusception is so 
likely to be followed by recurrence 
that operation is an addition that is 
preferable in many cases. The part 
of the bowel engaged in intussuscep¬ 
tion is of no value, and consequently 
excision of the bowel with anasto¬ 
mosis is in order, unless the patient 
is in a desperate condition, in which 
case we may simply approximate any 
two loops of bowel above or below 
the intussusception and unite these 
in the common way with a Lembert 
suture. 

Intussusception cannot progress 
beyond the point at which such anas¬ 
tomosis has been made. 

In emergency cases of intussuscep¬ 
tion, with the patient in extremis, the 
author likes the method of making a 
quick lateral anastomosis immediately 
above and below the area involved in 
the intussusception. If two traction 
sutures are used for approximating 
the loops of bowel to be anastomosed 
the work can be done very quickly and 
with little traumatism. 

The results of this procedure in 
emergency cases would seem almost to 
justify the simple resource as a regu¬ 
lar procedure. Intussusception cannot 
progress beyond the sutured area. The 


65 


ABDOMEN, SURGERY OF (MORRIS). 


invaginated part of the bowel in the 
intussusception may slough or under¬ 
go subsequent atrophic changes with¬ 
out adding a serious feature. 

The diagnosis should be followed 
by immediate operation which should 
be performed with the minimum 
amount of handling of the intestine 
and traumatism. The best incision is 
one that splits the rectus at the junc¬ 
tion of its middle and inner third, 
and extends one-third above and two- 
thirds below the umbilicus. If pos¬ 
sible the tumor mass should be 
grasped with two fingers and brought 
out through the incision. Reduction 
is successful in between 80 and 90 
per cent, of cases. Any other pro¬ 
cedure is so unsatisfactory that every 
effort should be made to complete 
reduction. If it fails, resection with 
end-to-end anastomosis probably of¬ 
fers the best chance of recovery; but 
the mortality is high, as the case is 
usually a neglected one. Formation 
of an artificial anus is attended with 
practically 100 per cent, mortality. 
Attempts to prevent recurrence by 
anchoring or shortening the mesen¬ 
tery are doubtful and prolong the 
operation. In closing the abdomen, 
tension sutures of silkworm gut 
should be inserted through the skin 
and aponeurosis, in addition to the 
layer sutures. Special efforts should 
be directed to combat shock. B. T. 
Tilton (N. Y. Med. Jour., Oct 7, 1916). 

Typhlitis.—Not readily distinguish¬ 
able from appendicitis, and is usually 
treated by simple opening of the 
abscess and drainage. 

Meckel’s Diverticulum.—One of the 
remains of the vitelline duct is some¬ 
times attached to the convex border 
of the intestine, and varies consider¬ 
ably in range, as well as in character. 

In some cases it closely resembles the 
part of bowel from which it springs. 
Consequently all varieties call for 
their respective forms of treatment. 

Sometimes the entire tube remains 

1—5 


as an opening at the umbilicus, but 
more commonly we have only the 
patent part of the tube near the bowel 
with a cord-like remainder extending 
to the umbilicus. Foreign bodies 
may escape into this diverticulum, or 
ordinary intestinal contents may 
result in exciting inflammation. Ad¬ 
hesions may produce angulation of 
the tube, interfering with circulation 
and leading to infection. Sometimes 
the diverticulum acts as a constrict¬ 
ing band in intestinal obstruction, in 
which case it takes part in acute in¬ 
flammatory process and may become 
gangrenous. Volvulus of the diver¬ 
ticulum may occur. 

Colonic Diverticula.—These may 
occur at any point, and often consist 
of anatomic defects opening into epi¬ 
ploic appendages. Increased pressure 
within the bowel at any time may 
lead to considerable enlargement of 
one or more such diverticula, and 
later with obstruction and inflam¬ 
mation. 

As in the case of one of the writers, 
diverticulitis, particularly when situated 
about the sigmoid region, may result in 
perforation into adjoining structures. In 
the writer’s case there was penetration of 
the wall of the bladder and also of the ad¬ 
joining segment of the ileum. Resection 
of the whole area of the diverticula in¬ 
cluding practically the whole sigmoid, 
and also of the tissues of the bladder and 
ileum by W. Wayne Babcock resulted in 
perfect recovery. Editors. 

Epiploic appendages when twisted 
upon their long axes may become 
congested and even gangrenous in 
very fleshy patients, but the treat¬ 
ment is simply for abscess which fol¬ 
lows. 

Diverticulitis of the sigmoid region 
is the most common, giving symp¬ 
toms quite similar to those of appen¬ 
dicitis, excepting for location of tender- 


66 


ABDOMEN, SURGERY OF (MORRIS). 


ness. The infiltrated tissues may re¬ 
spond to external applications of heat 
or cold, but frequently we must oper¬ 
ate for the abscess which remains. 

Report of several cases of diver¬ 
ticulitis. The writer has had suc¬ 
cess with temporary colotomy to rest 
the bowel, with subsequent resolu¬ 
tion of the inflammatory process, so 
that the colotomy wound could be 
closed and the lower part of the gut 
was able to function again. He has 
also inverted the projections, convert¬ 
ing them into polypi. Important to 
keep the bowels regular and to have 
the patient stop eating when symp¬ 
toms develop, if medical treatment is 
used. Turner (Lancet, Jan. 17, 1920). 

Wounds, Perforation from Within, 
etc.—In cases of solution of continu¬ 
ity in the intestine, whether from 
penetrating wounds from without or 
perforation from ulcers within, the 
course of procedure is the same. 
Laparotomy is performed and the 
wound or perforation sutured, unless 
the wounds are multiple and so close 
together that suture would cause too 
great a reduction of caliber, in which 
case anastomosis may be necessary. 

TYPICAL OPERATIONS OF 
THE INTESTINE.—Enterorrhaphy. 
—This term is applied to suture of 
the intestine for wounds or ulcers 
which are not extensive enough to 
require excision and anastomosis. 
The chief amount of intervention is 
in connection with the external inci¬ 
sions and examination of the intestine 
to determine the extent of the injury, 
which may involve more than the 
bowel itself. Hemostasis and cleans¬ 
ing of the peritoneal cavity will 
necessarily be required in traumatism 
from without, as well as in perforat¬ 
ing ulcer from within. It will often 
be necessary to incise the mesentery 
in order to complete the examination. 


and these incisions must always be 
sutured in such a way as to leave no 
point uncovefed by peritoneum. 

Perforation may, as a rule, be 
sutured without preliminary excision 
of tissue. The suture should run 
parallel with the long diameter save 
when the traumatism is near the 
pylorus. In this locality it should be 
applied in the transverse diameter. 
It is exceptional for an external 
traumatism to consist only of a single 
perforation of the intestine, for, as a 
rule, not only is the bowel itself 
penetrated doubly, but other portions 
of intestine and mesentery are in¬ 
volved in the knife or bullet wound. 
Hence single isolated trauma occurs 
most naturally from the internal 
perforations. 

Multiple perforations of the bowel 
and mesentery are adaptable for 
suture, no matter how numerous, if 
they are not too close together; but, 
when a portion of bowel is, so to 
speak, riddled by bullet or other 
wounds, it should be excised, unless 
the author’s resource in one case 
quoted above introduces a principle in 
addition. 

For suturing perforations a few 
points of interrupted Lembert silk or 
linen suture are usually sufficient. 
In multiple perforation or when there 
is suspicion of such, it is advisable 
to suture as soon as the wound is 
located, and before proceeding with 
further examination. 

The rule for determining the pos¬ 
sible limit of suture in contrast to 
excision is this: if the suture of one 
or more openings does not diminish 
the caliber of the intestine by more 
than a third, suture is indicated in 
place of excision. 

In perforation from typhoid ulcer 


ABDOMEN, SURGERY OF (MORRIS). 


67 


multiple traumatism is unusual, and 
the lesion in most cases is seated not 
far from the ileocecal valve. Owing 
to the general state of the patient the 
operation must be rapidly done, as a 
rule. An appendicitis incision usually 
suffices. 

The perforation is closed at once 
by a few interrupted sutures, or a 
purse-string suture. Cases of typhoid 
perforation do occur in which, either 
from the size, number or complica¬ 
tions of the lesion, enterostomy or 
enterectomy is required, but the con¬ 
dition of the patient sometimes makes 
it desirable to quickly fasten the 
bowel opening near to the external 
opening, and to do a secondary exci¬ 
sion operation after recovery from 
the typhoid. The friable character 
of tissues distended with serous in¬ 
filtrates also makes this expediency 
work necessary when the friable tis¬ 
sues refuse to bend freely to sutures. 
Even after simple suture it may not 
be advisable to close the abdominal 
wound, in contradistinction to the 
course pursued in suture of external 
wounds. The presence of peritonitis 
with adhesions may make it advan¬ 
tageous to leave the lower angle of 
the wound open for the purpose of 
a little drainage. 

Review of the literature of intes¬ 
tinal perforation in typhoid fever 
showed that those operated upon in 
which perforation was found con¬ 
sisted of 269 cases (from 1903 to 
1909); 156 of this number resulted 
fatally, giving a mortality of 57.99 per 
cent., while Harte and Ashhurst (all 
cases from 1884 to 1903), in a similar 
study, found 311 cases, with a mor¬ 
tality of 73.31 per cent. Charles Bag- 
ley, Jr. (Surg., Gynec. and Obstet., 
Aug., 1911). 

In a search through the literature 
since 1903, the writer found 133 re¬ 


ported cases of typhoid fever in which 
perforation occurred and was closed 
by suture. Of this number 68.5 per 
cent, died and 31,5 per cent, recov¬ 
ered. G. D. Head (Jour. Minn. State 
Med. Assoc., Aug. 1, 1911). 

Enterectomy.—Excision of portions 
of intestine is performed for a great 
variety of conditions, such as trau¬ 
matism, malignant tumors, actual or 
impending gangrene, etc. It is indi¬ 
cated, therefore, as an operation of 
choice or necessity in many of the 
conditions which constitute or give 
rise to ileus. The part to be removed 
may vary in length from two or three 
inches to a number of feet. In enter¬ 
ectomy, as in similar operations, the. 
actual operation requires much less 
time and a much simpler technique 
than the secondary stage of restoring 
the continuity of the intestine. There 
is in fact but one technique for the 
former, while the latter is not only 
practicable by quite different opera¬ 
tions, but each operation may be per¬ 
formed by a number of different 
methods. 

For the performance of the enter¬ 
ectomy proper, it is necessary to 
excise a portion of intestine with a 
certain amount of mesentery. After 
the external incisions and exploration 
of the abdomen the portion of intes¬ 
tine to be excised is, if necessary, 
freed from adhesions. This coil of 
intestine should be milked into the 
portions of the gut continuous, for 
which purpose the fingers of assist¬ 
ants must be used. After one-half of 
the coil is thus emptied in one direc¬ 
tion the fingers should compress the 
gut to prevent re-entrance of intes¬ 
tinal contents; the other extremity is 
then similarly treated. Instead of 
the fingers of assistants, clamps 
may be applied, one at either end and 


68 


ABDOMEN, SURGERY OF (MORRIS). 


some inches beyond the segment of 
gut to be excised. Loops of gauze 
may also be used, but in such a case 
the mesentery must be penetrated, 
and it is best to use the fingers of 
assistants as far as possible. 

Before excising, the mesentery 
must be ligated off close to the intes¬ 
tine,—about one inch distance. An 
approximate rule is to place a catgut 
ligature for every inch of mesentery. 
Another is to ligate less rather than 
more mesentery than is apparently 
called for. This is done on the prin¬ 
ciple of overcorrection, because if too 
much mesentery is sacrificed the 
edges of the anastomosis to be per¬ 
formed may suffer gangrene from 
interference 'with blood-supply. 

When all preliminaries have been 
completed the gut with its mesenteric 
stump is removed by means of the 
scissors. 

Case of resection of 300 cm. (10 
feet) of the small intestine and the 
cecum, with 20 cm. of ascending 
colon, owing to extensive ileocecal 
tuberculosis. The patient left the 
hospital at the end of the fourth week, 
having about 3 stools a day, but 2 
months after operation he returned 
with a severe cold and died shortly 
afterward of acute tuberculosis. Post¬ 
mortem examination showed the ab¬ 
domen in excellent condition. The 
remaining small intestine up to the 
duodenojejunal juncture was only 5 
feet, 7 inches, in length. Canaday 
(Annals of Surg., Ixix, 425, 1919). 

Report of experiments supporting 
Payr’s disinfecting method of mu¬ 
cous membrane of the intestine by 
painting with a 5 per cent, solution 
of iodine. In 67 per cent, of cases 
the iodine produced sterility, and in 
33 per cent, the number of bacteria 
was decreased. The procedure is es¬ 
pecially of value in the lower parts 
of the colon. L. Frankenthal (Beitr. 
z. klin. Chir., cxx, 614, 1920). 


Report of 282 consecutive cases of 
acute intestinal obstruction operated 
on, comprising 170 cases of obstruc¬ 
tion due to external hernia, 42 cases 
of carcinoma, and 70 other cases of 
obstruction. Saline infusion and 
morphine were used. 

The mortality was 9.3 per cent, in 
the cases not requiring resection and 
47.8 per cent, in those requiring re¬ 
section. Experience in determining 
whether the intestine is viable or not 
is important. When the walls are of 
an abnormal color and, in addition, 
feel limp and offer no sensation of 
firmness to the fingers, recovery is 
unlikely. E. R. Flint (Brit. Med, 
Jour., May 21, 1921). 

Enteroanastomoses.—These meth¬ 
ods of restoring continuity of the 
intestine after enterectomy comprise 
three distinct types. The first and 
most natural is end-to-end anasto¬ 
mosis or suture, which in most cases 
is the operation to choose. 

The second type is known as. the 
side-to-side laterolateral or simply 
lateral. It differs in scope from the 
preceding chiefly because it may be 
used between the small and large 
intestines, and small intestines and 
stomach. 

In acute intestinal obstructions 
from adhesions, unless the adhesions 
can be easily broken up, it is better 
to leave them alone. The loops above 
and below the obstruction should be 
joined by side-to-side anastomosis. 
The writer describes 7 cases in which 
he did this, with recovery and good 
results in 6 instances. If it is con¬ 
sidered best to resect the excluded 
segment, this can be done later after 
the general condition has improved. 
The intestine may be twisted when 
bound down by bands, and the circu¬ 
lation be so impaired that the slightest 
traction causes rupture. Ingebrigtsen 
(Norsk Mag. f. Laegevid., Feb,, 1921). 

The third type is known as end-to- 
side or terminolateral, or simply as 


ABDOMEN, SURGERY OF (MORRIS). 


69 


the implantation method. It is re¬ 
stricted in practice to implantation of 
a cut end of small intestine into the 
stomach or colon. The first-named 
has already been considered in part 
under pylorectomy. The latter is 
specifically known as ileocolostomy, 
or ileosigmoidostomy. 

Gastroenterostomy.—This operation 
consists of a lateral anastomosis 
between the stomach and some 
portion of the small intestine, either 
the duodenum or jejunum. Accord¬ 
ing as the intestine is united to the 
anterior or posterior stomach wall 
the operation is known as anterior or 
posterior gastroenterostomy. 

The operation is indicated in 
certain cases of gastric or duodenal 
ulcer, either as a primary resource or 
one secondary to pylorectomy or gas- 
trorrhaphy. Generally speaking the 
operation is one of necessity when 
milder measures have failed or are 
likely to fail. Minor indications for 
gastroenterostomy are found in con¬ 
traction of the pylorus from swallow¬ 
ing corrosive poison, in some cases of 
congenital stenosis of the pylorus, 
and finally in certain cases of cancer 
in this locality, as a palliative when 
pylorectomy cannot be performed. 

The operation is contraindicated in 
so-called medical diseases of the 
stomach, however severe these may 
be. 

The ideal operation is one in which 
the opening is made as nearly as we 
can to the pylorus and the proximal 
loop of jejunum, thus utilizing the part 
of the stomach which is commonly the 
lowest during the process of diges¬ 
tion. This will allow free regurgita¬ 
tion to the alkaline intestinal juices. 
Anastomosis with the cardiac part 
of the stomach would allow acid 


contents to escape in case of good 
digestion, and defect of pyloric diges¬ 
tion would be the result. In addition, 
cases have been reported in which 
jejunal ulcer has followed the form¬ 
ing of an opening at a point where 
acid contents could injure the tissues. 
The choice of procedure in gastro¬ 
enterostomy at the present time is 
certainly the so-called posterior no¬ 
loop operation, but the author has 
referred to older operations which 
are necessary at times. Even with 
ulcer of the stomach in the cardiac 
end of the stomach, the posterior no¬ 
loop operation should be made with 
the pylorus, if possible, to avoid the 
effects of gastric acidity at some 
distant point from the pylorus. The 
posterior no-loop operation is per¬ 
formed by making an opening 
through the transverse mesocolon in 
the usual way, avoiding the middle 
colic vessels. The posterior surface 
of the stomach being exposed, a 
portion near the pylorus part is 
chosen and drawn through the open¬ 
ing. The jejunal flexure close to the 
duodenum is found beneath the left 
of the mesocolon, and the proximal 
loop is employed for completing the 
gastroenterostomy, in such a way 
that when the parts are released from 
the fingers or clamps the intestine 
will hang in a direction which is 
almost vertical, but with a slight 
inclination toward the left or right, 
in a normal line of the long axis of 
the individual jejunum. This is the 
essential part of the posterior no-loop 
operation. 

Of 273 cases in which the writer 
had resorted to gastroenterostomy, 
170 were male and 103 female. The 
average age at which the operation 
was done was 44.3 years for males 
and 41.5 years for females. In those 


70 


ABDOMEN, SURGERY OF (MORRIS). 


cases seen shortly after operation in 
which one would not expect total 
restoration of gastric function, 20.9 
per cent, were free from complaint; 
49.8 per cent, were clinically com¬ 
fortable, and in 87.89 per cent, subjec¬ 
tive benefit had resulted. F. Smithies 
(Surg., Gynec. and Obstet., xxvi, 275, 
1918). 

The writer strongly advises loca¬ 
tion of the anastomotic orifice at the 
dependent point of the pyloric vesti¬ 
bule, as near as possible to the greater 
curvature of the stomach. Posterior 
gastroenterostomy as ordinarily per¬ 
formed does not always permit of 
recognition by the operator of the 
exact point of the stomach which he 
is bringing up through the narrow 
slit in the mesocolon. To obviate 
this, he recommends Lardennois and 
Okinczyc’s procedure of stripping the 
omentum from the colon, which al¬ 
lows the operator to expose the entire 
posterior surface of the stomach. The 
anastomosis having been effected, the 
margins of the opening in the meso¬ 
colon are simply sutured through the 
posterior cavity, and the great omen¬ 
tum is brought down over the trans¬ 
verse colon. P. Duval (Presse med.. 
Mar. 13, 1919). 

Regulation of the size of the gastro¬ 
enterostomy opening recommended. 
Where there is gastric atony, the 
contents will pour out too quickly 
unless the opening is small; yet it 
should be at the lowest point. With 
hypertonicity and a need for resting 
the stomach, the opening should be 
large and in the antrum, near the 
lesser curvature. If later required, the 
pylorus can then be closed. M^ivet 
(Presse med., Jan. 28, 1920). 

The cause of jejunal ulcer after 
gastroenterostomy is the pouring of 
acid gastric juice directly into the 
jejunum, which is physiologically fit¬ 
ted for only alkaline contents. Ac¬ 
cepted treatment of jejunal ulcer after 
gastroenterostomy is to disconnect 
the gastroenterostomy and perform a 
pyloroplasty. If a pyloroplasty had 
been done in the first instance, the 
jejunal ulcer would have been avoided. 


The writer had a case of jejunal ul¬ 
cer that occurred on the mesenteric 
border of the jejunum opposite the 
gastroenterostomy. J. Shelton Hors¬ 
ley (Trans. So. Surg. Soc.; Jour. 
Amer. Med. Assoc., Jan. 15, 1921). 

Stress laid on the superiority of 
trans- and supra-mesocolic gastro¬ 
enterostomy over ordinary posterior 
gastroenterostomy. When the for¬ 
mer is performed in simple cases it 
is not necessary to bring the trans¬ 
verse colon to the surface of the 
body. In difficult cases this allows 
the surgeon to operate outside the 
abdomen, and to place the opening in 
a good position. If the operative in¬ 
dication is clear, if exploration of all 
the posterior surface of the stomach 
is not necessary, and if the gastro¬ 
enterostomy is only the first stage of 
a gastrectomy, the gastrocolic liga¬ 
ment is depressed with the finger and 
the posterior wall of the stomach is 
exposed. If a very wide exploration 
of all the posterior wall of the stom¬ 
ach is necessary the intercolo-omental 
exposure of Duval is done. If pyloric 
exclusion by section is indicated and 
there is no suitable area on the pos¬ 
terior wall of the stomach to make 
the anastomosis the greater curvature 
is stripped of its vessels. R. Toupet 
(Presse med., xxix, 253, 1921). 

When postoperative jejunal ulcer 
occurs, the basis for it is usually 
laid during the first few weeks or 
months following gastroenterostomy, 
owing to neglect of dietetic precau¬ 
tions. Light and more frequent meals 
than normally are indicated. In 
other respects the diet should be 
regulated as in cases of gastric hyper¬ 
secretion. The marked acid-combin¬ 
ing capacity of casein and the inhibi¬ 
tory effect of fats on gastric secre¬ 
tion are emphasized. Cottage cheese, 
thoroughly mixed with milk or cream 
or softened and loosened up by stir¬ 
ring in beaten whites of eggs, with 
sugar, should be used plentifully, be¬ 
ginning a few days after the opera¬ 
tion. Of the fats, that of boiled beef, 
fresh and melted butter or, still bet¬ 
ter, vegetable oils (from 1 to 2 table- 


ABDOMEN, SURGERY OF (MORRIS). 


71 


spoonfuls after eating), are indicated. 
The antacid effect of the oils is more 
marked if taken separately than if 
mixed with the food. For the first 3 
weeks after the operation, the writer 
recommends a diet of boiled milk, 
fresh cottage cheese, 2 or 3 soft boiled 
eggs, fine wheat bread, butter, gruels 
and plain rice dishes. Later, mild 
cheese, mashed potatoes, vegetables 
passed through a sieve, and cooked 
fruits may be added. This diet should 
be adhered to for from 6 to 8 weeks, 
all meat or raw vegetables being ex¬ 
cluded. Favorite dishes and appetiz¬ 
ing odors should be scrupulously 
avoided, to obviate “psychic” gastric 
secretion. Von Noorden (Therap. 
Halb-Monatsh., Apr. 1, 1921). 

If the edges of the cut mesocolon 
are fastened to the stomach wall 
before completing this gastroenteros¬ 
tomy, it will obliterate the opening in 
the mesocolon, and this is desirable 
for avoiding subsequent hernia, if the 
patient’s condition allows us to 
follow ideal technique. When adhe¬ 
sions or extensive scarring or other 
mechanical reasons make the pos¬ 
terior no-loop operation of gastrojejun¬ 
ostomy difficult, we may use gastro- 
duodenostomy, instead. The anterior 
wall of the pylorus is joined with the 
descending part of the duodenum, but 
where we suture the mesocolon to the 
stomach it avoids the danger of sub¬ 
sequent hernia. 

It is practicable to insert a pre¬ 
viously swallowed Rehfuss gastro¬ 
duodenal tube well into the jejunum 
and to commence at once, on the 
operating table, the feeding of pep¬ 
tonized milk, dextrose and alcohol 
mixtures. Immediate jejunal feeding 
after gastroenterostomy is not only 
to be recommended in the operations 
performed for stenosis, but should be 
tried in all types of cases. Andresen 
(Annals of Surg., May, 1918). 

Anterior Gastroenterostomy. 
—This, the original procedure, has 


been replaced in most cases by the 
posterior operation, but is still per¬ 
formed when the posterior wall is 
unaccessible by reason of adhesions 
or organic disease. A fairly good 
rule is for the surgeon to do which¬ 
ever operation he can do most easily 
in any given case, but the anterior 
operation gives more postoperative 
complications. The operation is as 
follows:— 

After the stomach has been fully 
exposed, its anterior wall is so 
grasped that the fold which is to be 
the seat of the anastomosis runs 
obliquely across from right to left, 
and from below upward. The intes¬ 
tine is similarly grasped about 
eighteen inches below the duodeno¬ 
jejunal junction and the two struc¬ 
tures placed side by side. 

The anastomosis is then carried 
out as in all similar procedures, one- 
half the outer plane of sutures being 
inserted before the incision is made. 
Details of technique will be con¬ 
sidered under the posterior operation. 

Posterior Gastroenterostomy.—The 
external incision is that used for 
other operations on the lower portion 
of the stomach and the pylorus, 
passing through the right rectus 
by blunt dissection, the posterior 
sheath and peritoneum being divided 
together. The incision is largely an 
exploratory one, for despite the evi¬ 
dence of a pyloric ulcer, for example, 
the entire stomach and duodenum 
with the neighboring viscera must be 
examined for complications and pos¬ 
sible contraindications. The jejunum 
must also be examined with especial 
reference to its relations with other 
organs. The natural direction should 
be learned, for this may be to the 
right, left, or directly downward, and 


ABDOMEN, SURGERY OF (MORRIS). 


72 

in bringing the intestine in contact 
with the posterior wall the original 
direction must be conserved. 

In order to gain access to the 
posterior wall it is necessary to go 
through the transverse mesocolon, 
the incision being ample enough to 
enable the posterior wall to be drawn 
outward; but the incision in the meso¬ 
colon, to avoid opening large blood¬ 
vessels, should be first made small 
and then enlarged by stretching with 
the fingers. 

Generally speaking the portion of 
this wall to be selected for anasto¬ 
mosis is at the lowest point of the 
organ, which is considerably nearer 
to the pylorus than to the cardia and 
fundus. The author likes to cut 
through the ligament of Treitz when 
approaching the posterior stomach 
wall. This brings one to a convenient 
part of the jejunum for the no-loop 
operation. He prefers traction sutures 
rather than instruments for approxi¬ 
mating stomach and ileum during op¬ 
erative procedure. The portion to be 
incised for the anastomosis is pinched 
up in a direction corresponding to the 
natural direction of the jejunum itself. 
The latter is also grasped an inch or 
two below the duodenojejunal junction. 
As in all such anastomoses, a portion 
of the outer plane of sutures is intro¬ 
duced before the incisions are made. 
This is a continuous seromuscular 
suture, intended to fix the two 
structures together and furnish a 
guide to the incisions. The latter, 
some three inches in length, are not 
simple linear incisions, but a small 
spindle-s'haped portion of tissue is 
excised. The two openings thus 
made are now sutured together by 
through-and-through stitches of the 
penetrating type, the two posterior 


margins being first united, and then 
the anterior niargins, the inner layer 
of sutures being thus completed. 
The fingers or clamps are removed, 
and the outer plane of serous sutures 
completed. 

In performing the posterior opera¬ 
tion the writer advises that the oper¬ 
ator locate the peritoneal suspensory 
ligament or band which extends from 
the transverse mesocolon to the upper 
part of the jejunum. Immediately 
above this band, in the mesocolon, is 
an area in which there are no impor¬ 
tant blood-vessels. The suspensory 
band having been stripped away, and 
a transverse incision made in the 
above-mentioned area of the meso¬ 
colon, the posterior aspect of the 
stomach may be drawn through this 
opening and the denuded jejunum at¬ 
tached to it, the attachment thus be¬ 
ing without strain or loop and follow¬ 
ing the normal direction of the 
jejunum. Mayo (Annals of Surg., 
Jan., 1908). 

New method of gastroenterostomy 
accompanied by less traumatism to 
tissues than where clamps are used, 
sure to be free from postoperative 
hemorrhage, and more readily per¬ 
formed. A celluloid suture is inserted 
through the stomach and intestine at 
each end of the sites chosen for the 
new communication. By keeping 
traction on these, the jejunum and 
stomach are kept in close approxima¬ 
tion. The usual posterior stitch is 
next introduced. The peritoneal cav¬ 
ity is then walled off and incisions 
made in both viscera close to the line 
of suture exposing the blood-vessels. 
These, usually 5 or 6 in number, are 
doubly secured with hemostats and 
the mucosa opened between them. 
Taking first the posterior wall, each 
pair of vessels, one gastric and one 
intestinal, is ligated with a single 
strand of chromic catgut, after draw¬ 
ing the edges together by means of 
the two forceps in closest proximity. 
These ligatures not only prevent any 
hemorrhage, but hold the edges of 


ABDOMEN, SURGERY OF (MORRIS). 


73 


the mucosa in firm apposition. The 
anterior edges are drawn together by 
beginning at the end farthest from 
the surgeon. The 2 forceps which 
lie opposite each other are held to¬ 
gether by an assistant. The right end 
of the ligature is passed around the 
forceps on the intestine from right to 
left, the left end is passed around the 
forceps on the intestine from left to 
right so that the ends emerge be¬ 
tween the forceps, beneath the loop 
of the ligature. The forceps are now 
brought parallel to the long axis of 
the wound, and rolled toward each 
other, inverting the mucous edges of 
the wound. Each succeeding pair of 
vessels is dealt with in the same way. 
The rest of the procedure is much as 
in the usual operation. Of the last 
40 patients, 38 recovered and 2 died, 
these 2 having inoperable carcinoma 
and succumbing to exhaustion and 
pneumonia. F. T. Stewart (Annals 
of Surg., Ixvi, 334, 1917). 

Roux^s Operation .—The Y-opera- 
tion of Roux differs notably from the 
typical procedures just enumerated, 
being a combination of the ‘anasto¬ 
moses, both being examples of im¬ 
plantation of terminolateral anasto¬ 
moses. The jejunum having been 
divided across, the peripheral seg¬ 
ment is implanted into the posterior 
surface of the stomach, while the 
proximal segment is implanted into 
the jejunum. 

It is no longer held desirable to use 
mechanical devices in most gastro¬ 
enterostomies, although such aids 
were of great importance at one time 
in giving us confidence to advance 
to a simpler technique. 

Gastroenterostomy is liable to be 
succeeded by certain typical compli¬ 
cations. Among these are hemor¬ 
rhages, sometimes inexplicable, but 
now generally believed to be due fre¬ 
quently to overlooked ulcers, or to 
imperfect suturing, or to the use o£ 


too-fine suture material which cuts 
out when the patient vomits. In 
bleeding ulcer of the stomach it is 
sometimes extremely difficult to 
recognize all of the bleeding surface 
while the tissues are held in tension. 
Relaxation of tissues and pressure on 
the viscera with the fingers or with 
gauze may start a free bleeding which 
localizes the ulcerated area. Post¬ 
operative ileus may develop, which 
may be due to obstruction from adhe¬ 
sions, to internal strangulation, or to 
angulation of bowel, particularly in 
the anterior operation, if the loop is 
not supported by side sutures in the 
omentum. 

Aside from vomiting, which is 
symptomatic of this obstruction, we 
may have a non-obstructive type 
which supervenes at a late period 
(one or two months following opera¬ 
tion). The nature of the vomiting is 
not always clear, but, since operators 
have sought to preserve the natural 
direction of the jejunum, cases of 
obstruction and vomiting have been 
much less frequent. 

A complication of considerable grav¬ 
ity is peptic ulcer of the jejunum, at¬ 
tributed once to the action of digestive 
enzymes, but now regarded as having 
a common origin with ordinary gastric 
and duodenal ulcer, viz., hyperacidity 
(hyperchlorhydria) and toxic injury 
of terminal arteries. To lessen the fre¬ 
quency of this complication it is ad¬ 
visable that every patient to be 
operated upon be first treated for 
hyperchlorhydria. Peptic ulcers of the 
jejunum run a similar course to that 
of ulcers higher up, terminating at 
times in perforation. 

Condition of the patient one year 
or more after gastroenterostomy in 
175 cases, 150 benign, 25 malignant:— 


74 ABDOMEN, SURGERY OF (MORRIS). 


Benign (150).—The immediate 

mortality (death within thirty-five 
days) was 10 per cent. Eighteen died 
within the first year (12 per cent.); 
22 died of their gastric disorder 
within five years (14.6 per cent.). Six 
patients are alive, but have been oper¬ 
ated upon within one year. 

Of the 126 patients who survived 
the operation, and have been under 
observation for one year or more, 81 
(or nearly two-thirds) were reported 
as entirely recovered, or well; 8 as 
much better, and 31 (nearly 1 in 4) as 
little or no better. Of the 150 patients 
89, or 60 per cent., were much better 
or entirely well; fully 30 per cent, 
died or were little or no better at the 
time of report. 

Twenty-five cancer cases are re¬ 
ported, 20 being in men. Ten patients 
died within one month of the opera¬ 
tion, an immediate mortality of 40 per 
cent. One is still living, two years 
after operation, another six months, 
and another four months. Ten pa¬ 
tients lived more than four months 
after operation. Six of these were 
temporarily much improved, and 
gains of weight ranging from eighteen 
to forty-seven pounds are recorded. 
Two patients received no benefit at 
all from the operation. Bettmann and 
White (Med. Record, Oct. 9, 1909). 

In gastroenterostomy the new 
formed anastomosis is the site of a 
healing ulcerated surface for a period 
of 14 days, and for the first 5 or 7 
days, the process is largely destruc¬ 
tive. For the first 2 weeks, the diet 
should be as light as is compatible 
with maintenance of strength. Flint 
(Annals of Surg., Feb., 1917). 

The new train of symptoms some¬ 
times following gastroenterostomy is 
usually due to peptic ulcers in the 
stomach or bowel in the vicinity of 
the new stoma, or adhesions. 

All of these various complications 
or disturbances usually yield to a 
liquid diet, large doses of bismuth, 
and gastric lavage, but when these 
fail, duodenal or jejunal alimentation 
is of great benefit. Of 10 such cases 
8 were so much improved that no 


further treatment was necessary. Max 
Einhorn (Med. Rec., June 16, 1917). 

Case of spasmodic occlusion of the 
anastomotic mouth after gastroen¬ 
terostomy in which complete success 
was obtained by administering bella¬ 
donna. The author is satisfied that 
his patient like Zweig’s was vago¬ 
tonic, with gastric hypertonia. L. 
Urrutia (Arch, des mal de TAppar. 
digestif, lx, 84, 1917). 

Fatal postoperative diarrhea some¬ 
times occurs. Its nature is obscure 
and seems to depend upon derange¬ 
ment of bowel function due to shock 
to the sympathetic ganglia. 

End-to-end Anastomosis after En- 
terectomy.—This may be effected by 
suture, or Murphy’s button. The 
suture methods in use comprise the 
simple direct suture, the combination 
of suture and invagination, the 
Connell method, etc. 

Simple Suture. —The' mesentery is 
first united by transfixing both the 
cut edge of the gut just beside the 
mesentery, and then the latter close 
to its insertion. The same through- 
and-through suture is then passed in 
the reverse order through the opposite 
mesentery and gut. A duplicate 
suture is now passed through the 
other side, or the same suture may 
have its other end threaded in a 
needle and be used for this purpose. 
When this suture is tightened the 
gap in the mesentery is closed with 
approximation of the cut ends. The 
remaining step is suture of the latter, 
and this may be done by carrying the 
original two-tailed mesenteric suture 
from its knot around the circum¬ 
ference of the gut on either side until 
most of the circumference has been 
sutured. The opening which remains 
is closed with an outside Lembert 
suture. The rent in the mesentery is 
closed with a few points of catgut. 


ABDOMEN, SURGERY OF (MORRIS). 


75 


Intestinal anastomosis by invagina¬ 
tion, cuff and suture, is probably the 
simplest, quickest, safest, easiest 
method and the freest from unpleas¬ 
ant complications. 

The proximal end should extend 
from 1 to IV 2 inches into the distal 
end in end-to-end anastomosis, though 
less in lateral anastomosis. 

The invaginated ends and portions 
of gut eventually atrophy without 
stenosis. 

Fine round needles, silk or linen 
thread, and interrupted rather than 
continuous sutures should be used. 
B. M. Ricketts (Trans. West. Surg. 
and Gynec. Assoc., 1919). 

MaunselVs Method .—The divided 
surfaces of intestine are placed in 
rough apposition by four traction 
sutures at equidistant points, the first 
at the mesenteric insertion. The 
next step is to introduce a pair of 
forceps through the intestinal wall 
from without inward, and to this end 
a slit is made in the long diameter of 
the bowel, one (either side) segment 
opposite the mesenteric insertion and 
about one and one-half inches from 
the cut edge. With this forceps 
the loose ends of the traction su¬ 
tures, previously twisted together, are 
tightened with production of an in¬ 
vagination of the distal into the 
proximate segment, the two serous 
coats being in contact. In this posi¬ 
tion the two edges are united with 
a chromicized-gut suture applied 
through-and-through, the traction su¬ 
tures are removed, and the invagi¬ 
nated segment replaced. An external 
durable Lembert suture is now ap¬ 
plied. 

Connell Method .—As in the preced¬ 
ing operation, four traction sutures 
are applied, and the two cut edges of 
intestine are sutured, one-fourth at a 
time. The traction sutures which 


limit each quadrant are tightened in 
turn, and the intervening intestine 
joined by applying a right-angled 
through-and-through suture. As soon 
as a portion of the gut is reunited 
one of the tractors becomes unneces¬ 
sary and is removed. At the close of 
the suturing the two free ends are 
threaded within the lumen of the 
intestine upon a ligature carrier, 
brought outside and tied, and the 
knot is then worked back on the 
inside of the gut. 

New method of aseptic enterec- 
tomy and enteroanastomosis is de¬ 
scribed, which is based on crushing 
with clamps of the visceral layers of 
the parts operated on. In end to end 
anastomosis, Kocher forceps are 
placed at the margins of the pre¬ 
viously crushed sections of bowel, 
and the piece of bowel to be taken 
out removed by passing the scalpel 
along the closed forceps. The 2 for¬ 
ceps are then placed side by side, 
and 2 continuous seroserous sutures 
carried successfully through the ad¬ 
joining bowel tissues along one side 
of the forceps, next round their tips, 
and finally back again along the other 
side. The forceps are then removed 
—the bowel ends having already been 
united all around except at one point, 
the point of entrance of the forceps— 
and a grooved director is passed in 
and moved from side to side, thus de¬ 
taching the previously adherent mar¬ 
gins of the serous coats, unfolding 
the mucous and muscular coats, and 
restoring communication between the 
two bowel ends. The suture ends 
hanging out are now tied, thus clos¬ 
ing the opening. In laterolateral 
anastomosis, as in gastroenteros¬ 
tomy, the 2 linear portions of visceral 
wall to be joined are first crushed; 
2 continuous sutures are then passed 
completely round these portions ex¬ 
cept at one point, through which 
scissors are introduced to cut through 
the serous coats before the sutures 
are tied. The perfect results ob- 


76 


ABDOMEN, SURGERY OF (MORRIS). 


tained were confirmed by post-mor¬ 
tem examinations. Gudin (Paris 
Med., Dec. 16, 1916). 

Axial or end-to-end anastomosis of 
the colon has not hitherto been pop¬ 
ular because of its high mortality. 
The author points out that the real 
reason why axial union often failed 
is that the arteries supplying the 
colon pass round in a circular direc¬ 
tion with very little anastomosis. 
Leakage after axial union is gener¬ 
ally on the side opposite to the mes¬ 
entery. All that is necessary to se¬ 
cure a good result in axial anasto¬ 
mosis is to cut the bowel across at 
an angle of 45 degrees from the 
mesentery outward, i.e., with more 


insertion. The tails are then carried 
down on either aspect of the intes¬ 
tinal segment to the point opposite 
the mesenteric insertion, the suture 
of chromicized gut being applied 
overhand. The two tails of the 
suture having been tightened upon 
the halves of the button, these are 
then joined and locked. The rent in 
the mesentery is now repaired and an 
outside durable Lembert suture ap¬ 
plied over the inside suture. Great 
care is taken to cover the bowel inci¬ 
sion with peritoneum at the mesen¬ 
teric attachment. 



bowel removed on the free than the 
attached side, thus insuring a good 
blood-supply to the whole of the 
sutured edges. The writer has used 
this method for years, with almost 
uniformly perfect results. With the 
resected portion of bowel a wedge of 
mesentery is removed. The bowels 
are moved on the second day by a 
small gruel enema, assisted, if neces¬ 
sary by pituitary extract. P. Lock- 
hart-Mummery (Surg., Gynec. and 
Obstet., Feb., 1917). 

Murphy Button. —Purse-string su¬ 
tures are applied at either divided 
segment and tightened upon the 
halves of the button. The suture for 
each side is a two-tailed one, and 
first transfixes the mesentery at its 


Lateral Anastomosis.—In this oper¬ 
ation there is no restoration of the 
continuity originally present, but a 
purely artificial opening is created 
between the two segments of intes¬ 
tine. Such an operation may be 
termed an internal enterostomy, 
which agrees with an external colos¬ 
tomy to this extent: that in each case 
a fistulous communication is set up. 
In this connection we need only 
describe the operations of entero- 
enteric anastomosis and ileocolos- 
tomy, for the gastroenteroanasto¬ 
moses are considered elsewhere. 

This anastomosis may be effected 
in several ways—preferably by su- 


ABDOMEN, SURGERY OF (MORRIS). 


77 


ture, clamps, elastic ligature, or 
Murphy’s button may be desirable in 
special cases. 

Suture ,—The loop of intestine is 
emptied and prevented from refilling 
by finger pressure, clamps, or gauze 
loops. Excision having been per¬ 
formed, the two cut ends are closed 
by the insertion of inverting Lembert 
sutures, the slack of the mesentery 
being included in the inversion. A 
double cul-de-sac thus results, the two 
parts of which are to be joined in the 
resulting lateral anastomosis. The 
two ends are apposed for a space of 
four inches or more, and a single line 
of Lembert sutures applied at their 
junction. The segments being now 
in their permanent position, they are 
incised close to the suture line with 
scissors. As a rule, the length of the 
incisions should be three inches. 

A continuous suture of chromicized 
gut is carried along both sides of 
the new opening, thus constituting 
the inside suture plane. The out¬ 
side plane is completed by a second 
durable Lembert suture. Of mechani¬ 
cal aids, Murphy’s oblong button is 
the best for general use, the tech¬ 
nique being akin to that of the round 
button for end-to-end anastomosis. 

Enteroexclusion.—The temporary 
operation is not a procedure compara¬ 
tive to enterectomy. It is without 
some of the dangers of the radical 
operation, and may be performed 
rapidly. The operation consists in 
division of the intestine and lateral 
enteroanastomosis, or, in the case of 
the colon, enteroimplantation. A dis¬ 
eased portion of the intestine which 
would otherwise demand extirpation 
is then excluded from the intestine. 
If the distal end is closed the opera¬ 
tion is known as partial or unilateral 


exclusion; but, if it is also made 
the subject of an anastomosis, the 
intervention is known as double or 
complete occlusion. The chief indi¬ 
cations are tuberculosis, fistulae (espe- ' 
cially multiple ones), and malignant 
disease. 

Unilateral Exclusion .—No attempt 
is made to close the excluded loop at 
its lower extremity, which is just 
above the anastomosis, as there is no 
danger of stagnation of feces in this 
locality. Technically the operation is 
well adapted for the use of Murphy 
buttons. No details need be given, 
as these are identical with the details 
of anastomoses after excisions. Its 
chief use is in emergency cases. 

Bilateral Exclusion .—Both ends of 
the excluded loop are closed, and 
either two anastomoses are made or 
one end only is anastomosed while 
the other is left in the external 
wound. When the operation has been 
done for actual intestinal fistulse, both 
ends of the loop may be closed, as 
the loop will then be drained suffi¬ 
ciently through the fistulous open¬ 
ings. If exclusion is done for 
carcinoma it is better to leave one 
end of the loop in the external wound, 
for, when the operation has been done 
for any incurable condition, exclusion 
must be followed sooner or later by 
excision. 

The writer warns against opera¬ 
tions on the intestinal tract in which 
no outlet is provided for the intes¬ 
tinal mucous secretion. This over¬ 
sight sometimes leads to fatal results. 
When stimulated into greater activity 
by irrigation or infection, the amount 
of secretion may be enormous, as in 
colitis, and even result fatally. G. G. 
Turner (Brit. Med. Jour., iv, 227, 
1916). 

Where a patient with toxemia only 
from the small bowel becomes a sur- 


78 


ABDOMEN, SURGERY OF (MORRIS). 


gical case, the writer considers the 
Lane short circuit ileocolostomy the 
operation of choice, but if, as is 
usually the case, the obstructed ileum 
is accompanied by a dilated and 
atonic cecum, the Mayo right-sided 
colectomy is the proper operation. 
The Mayo technique is free from the 
criticism of the Lane technique, in 
that the intestines are not handled 
after the colon has been opened, 
greatly lessening the possibility of in¬ 
fection, while there is no blind pocket 
left to become impacted. R. Smith 
(Surg., Gynec. and Obstet., Nov., 
1916). 

Actual colectomy must be aban¬ 
doned as impracticable because of 
late unpleasant complications. Even 
after simple ileosigmoidostoniy, pro¬ 
nounced anastalsis supervenes, ag¬ 
gravating the toxemia. In what the 
writer terms physiological colectomy, 
after the ileosigmoidostomy with side 
to side anastomosis has been estab¬ 
lished, the sigmoid is divided in its 
upper arch as near as practicable to 
the lower end of the distal sigmoid. 
The open end of the distal segment is 
then fixed in the lower angle of the 
wound and the open end of the proxi¬ 
mal colon in the upper angle. Fin¬ 
ally, a catheter—afferent— is inserted 
into the open terminal ileum, the tip 
being carried into the cecum, and a 
large tube—efferent—into the open 
end of the colon. Thus isolated, the 
colon is irrigated to unload its toxic 
fecal content and then left to atrophy 
from disuse. Where a secondary 
actual extirpation becomes necessary, 
the difficulties are diminished owing 
to the atrophy of the colon. The 
primary mortality from physiological 
colectomy should be practically nil, 
though as yet the percentage of ulti¬ 
mate recoveries have not been en¬ 
tirely satisfactory. C. A. L. Reed 
(Trans. Amer. Med. Assoc.; N. Y. 
Med. Jour., June 30, 1917). 

Enterostomy, Jejunostomy, Ileos¬ 
tomy.—The establishment of an arti¬ 
ficial opening in the small intestine is 
not necessarily for the purpose of 


establishing an anus contra naturam, 
but may be done simply for relief of 
distention or, like gastrostomy, for 
the introduction of nutriment. The 
only condition justifying this form of 
intervention is an absolutely irre¬ 
mediable stricture of the pylorus with 
resulting starvation. 

The operation may be done like a 
gastrostomy, using a tube or catheter. 
It is preferable, however, to sacrifice 
the integrity of the intestine by divi¬ 
sion and anastomosis, leaving a cut 
end in the external wound. The 
point selected is in the jejunum, about 
eight inches below the duodeno¬ 
jejunal angle. The intestine is 
divided at this point and the central 
end implanted six or eight inches 
farther along the gut. The peripheral 
end is not treated like the stomach 
cone in gastrostomy, i.e., it is passed 
out of the external incision, beneath 
the skin, and out at a special opening 
(see Gastrostomy). The original 
wound is closed plane by plane while 
the fistular wound is sutured to the 
divided intestine. 

Ileostomy is sometimes performed 
for establishing an artificial anus, 
necessarily in cases where ileocolos¬ 
tomy or simple colostomy is insuffi¬ 
cient for drainage. The lowest pos¬ 
sible part of the ileum is selected, the 
incision being made one and one-half 
inches above Poupart’s ligament. In 
this operation it is not necessary to 
divide the intestine, and the technique 
does not differ from that of ordinary 
colostomy. 

Jejunostomy advised for the relief 
of obstruction following operation, in 
cases of long standing acute obstruc¬ 
tion from some unknown cause, and 
for nutritive purposes in cases of 
widespread cancer of the stomach ob¬ 
structing the cardia and leaving little 


ABDOMEN, SURGERY OF (MORRIS). 


79 


room, for gastrostomy, cases of ex¬ 
tensive laceration of a cancer of the 
stomach made accidentally during ex¬ 
ploration, and extreme cases of nerv¬ 
ous vomiting of girls from 18 to 25 
years of age. The operation for pur¬ 
poses of nutrition is performed 
through a midline or left lateral in¬ 
cision; for the relief of obstruction it 
is best to re-open the former incision 
unless it is infected. In obstruction 
cases the operation should be per¬ 
formed as soon as the evening of the 
third day or on the fourth day. If 
there is no general peritonitis and the 
obstructive condition is recognized 
early, the operator may explore the 
region of the primary operation, sep¬ 
arating bands of adhesions or kinks 
and relieving the obstruction. If 
jejunostomy is considered necessary, 
a No. 10 English catheter is inserted 
a few inches into the lining of the 
selected gut and fixed to the bowel 
by a purse-string suture of chromic 
catgut or silk. The catheter is then 
depressed into the wall of the bowel, 
which is sutured over it for an inch 
and a half. It is passed through a 
perforation in the omentum and 
brought out through the incision, 
sutures being passed through the 
peritoneum, the omentum, and the 
intestine on each side of the tube. 
In the larger number of a series of 
43 cases the operation was necessi¬ 
tated by cancer, and was palliative. 
Twelve of the patients died within a 
week, and 4 more within a month, 
but in all cases the operation served 
its purpose of affording temporary or 
permanent relief. C. H. Mayo (Jour¬ 
nal-Lancet, Dec. 15, 1917). 

Surgery of the Appendix—The 
vermiform appendix, 'while nomi¬ 
nally a portion of the colon, is subject 
to peculiar affections 'which, in them¬ 
selves often trivial, are prone to give 
rise to the most serious surgical com¬ 
plications. The mere removal of the 
appendix makes up a small portion 
of the actual surgery of this organ, 
'which includes the surgical manage¬ 


ment of appendix-abscesses, appen¬ 
dix-peritonitis, and other complica¬ 
tions. Hence the description of 
appendectomy as a typical operation 
representing the surgery of the organ 
is a small part of the subject, and re¬ 
quires elaboration only because of the 
different complications surrounding 
the work. 

The typical operation in a case of 
early infection, or in fibroid degener¬ 
ation of the appendix, consists in 
bringing the appendix to the outside 
of the abdomen, ligating it like an 
artery with catgut at two points, one- 
fourth inch apart. We sever the 
appendix between these two points of 
ligation and carry a drop of 95 per 
cent, carbolic acid into the lumen of 
each stump. The scissors or knife 
with which the severing is done is not 
used again at the operation, because 
the instrument is now infected, and is 
to be put aside in a safe place. The 
carbolic acid has sterilized the tissues 
with which it has come in contact 
instantly, and in order to stop any 
further and undesirable action we 
neutralize the carbolic acid with a 
few drops of alcohol applied with a 
pledget of cotton. 

The next step is ligation of the 
mesappendix with catgut at as many 
points as desirable in any particular 
case. In some cases the mesappendix 
allows a safe ligation with a single 
ligature. In other cases where it has 
a particularly broad attachment, four 
or five ligatures may be required. It 
is quite as important in ligating mes¬ 
appendix as in ligating broad liga¬ 
ment after an operation for ovariot¬ 
omy, not to include too much tissue 
in any one ligature, and not to cut 
the stumps too short above the liga¬ 
ture, for the reason that vomiting and 


80 


ABDOMEN, SURGERY OF (MORRIS). 


other movements subsequent to the 
operation are particularly apt to force 
off these ligatures and give rise to 
secondary hemorrhage or opening of 
the lumen of the appendix. The last 
step after cutting away the mesap- 
pendix consists in scarifying the 
peritoneum of the cecum near the 
stump of the appendix that is left, 
with the point of a needle, in order to 
insure an abundance of lymph exuda¬ 
tion which will wall in the stump. 

The author has employed practi¬ 
cally all of the fanciful methods of 
treatment of the stump which have 
been described by authors, and has 
dropped all but this simple method, 
which saves time. At one hospital 
where four thousand appendectomies 
performed by this method have been 
tabulated, there were only two cases 
of trouble due to the form of pro¬ 
cedure, and both of these were due to 
the slipping of a ligature, both liga¬ 
tures having been tied by the same 
member of the house staff, who may 
not have learned to tie square knots, 
or who may have cut stumps too 
short. Where old adhesions make it 
difficult to bring the appendix out 
upon the abdominal wall, this simple 
method of treatment of the stump 
does away with many difficulties. 

In cases of acute infection with 
abscess, with dense new or old adhe¬ 
sions, it is extremely unwise to at¬ 
tempt to bring the cecum to the 
surface in order to carry out peculiar 
methods of treatment of the stump of 
the appendix, and in such cases it will 
suffice if we snap a pair of forceps 
upon the appendix close to the cecum, 
and remove the appendix with the 
finger without further detail, unless 
one wishes to leave another pair of 
forceps on the mesappendix. The 


forceps left in place for twenty-four 
hours serve to protect also the small 
drain placed alongside. At the end 
of twenty-four hours the forceps may 
be removed, and no more attention 
given to the stump of the appen¬ 
dix. In these far-advanced cases the 
arteries of the mesappendix have 
commonly been occluded by pro¬ 
liferating endarteritis and the veins 
are filled with thrombi, so that the 
hemorrhage amounts to nothing more 
than a moderate degree of oozing 
cared for by the capillary drain. 
Such simple treatment does away 
with a great part of the dangerously 
severe part of operative work which 
in the third era of surgery has often 
been thought necessary. Treatment 
of abscesses and peritonitis of appen¬ 
dix origin is discussed under the 
general head elsewhere in the article. 

See also Appendicostomy and the 
article on Appendicitis in the second 
volume of this work. 

Analysis of 822 cases of appen¬ 
diceal operation at the Cook County 
Hospital, Chicago, between Novem¬ 
ber, 1912, and February, 1916. Of the 
58 terminating in death, 17 showed 
general peritonitis at the time of op¬ 
eration, and should be considered as 
cases of general peritonitis. Deduct¬ 
ing them from the 58, the mortality 
is 4.98 per cent, for uncomplicated 
acute appendicitis. Of 445 patients 
operated on for simple acute appendi¬ 
citis, 5 died, a mortality of a trifle 
over 1 per cent. Of 266 patients op¬ 
erated on for acute appendicitis—sup¬ 
purative, gangrenous, perforating— 
with abscess, 6 died, a mortality of 
2.2 per cent. Of 127 patients having 
gangrenous appendicitis without ab¬ 
scess formation; 7 died, a mortality 
of 5.5 per cent. Of the series, 150 
cases occurred in children under 15 
years of age. Of these, 138 recovered 
and 12 died, a mortality of 8 per cent. 
The following conclusions are drawn: 


ABDOMEN, SURGERY OF (MORRIS). 


81 


General peritonitis is still the most 
frequent complication of acute appen¬ 
dicitis. Drainage tubes, gauze, etc., 
should be removed gradually to avoid 
inclusions and subsequent spread of 
infection. Early operation means a 
low mortality. Abscess formation 
may be considered evidence of resist¬ 
ing power on the part of the organ¬ 
ism. Fecal fistula, while compara¬ 
tively frequent and annoying, has 
little importance in increasing mor¬ 
tality. Abortion is not greatly to 
be feared if appendicitis occurs dur¬ 
ing pregnancy. P. F. Morf (Jour. 
Amer. Med. Assoc., Ixviii, 902, 1917). 

Report on local anesthesia in 60 
operations for acute and chronic ap¬ 
pendicitis. Three-quarters of an hour 
before operation % grain (0.016 Gm.) 
of morphine is given hypodermatic- 
ally, and usually repeated just before 
operation unless the patient is 
drowsy. A 1 per cent, novocaine 
(procaine) solution is used, to the 
ounce of which 20 drops of 1:1000 
solution of epinephrin are added. 
The meso-appendix is injected as 
well as the wall layers. There was 
no mortality. The average time of 
operation was 22 minutes, the length 
of time being due to the waiting for 
action of the anesthetic on the sep¬ 
arate abdominal layers and mesen- 
teriolum. Postoperative distention 
was usually absent. The day follow¬ 
ing operation, the author gives pituit- 
rin 1 c.c. (16 minims), and one-half 
hour later a rectal irrigation or high 
enema. The average stay in bed was 
less than 7 days. The chronic cases 
usually left the hospital 2 or 3 days 
later. Recent adhesions could be sep¬ 
arated without pain; when dense, 
novocaine was injected. J. Wiener 
(N. Y. Med. Jour., Aug. 2, 1917). 

In single suture appendicectomy, 
advised by the author in pelvic oper¬ 
ations, the tip of the appendix is 
picked up in a clamp, and a long 16- 
to 18- inch suture carried through 
the clear triangular space at its base 
and tied, thus ligating the appendic¬ 
ular artery. The mesentery is then 
cut free, leaving a small stump. Con- 

1-' 


tinuous with the appendix, at its base, 
is the longitudinal stria of the cecum. 
One-fourth of an inch from this base 
the needle is carried with a Lembert- 
Czerny stitch as a fixation suture to 
prevent the ligature from slipping. 
The needle is now carried back and 
inserted through the mesentery be¬ 
tween the first ligature and the base 
of the appendix, and tied to the 
proximal end of the first knot. The 
appendix is clamped, cut, and the 
stump treated with carbolic acid and 
alcohoL Anterior to the mesentery 
and upon the lower portion of the 
cecum, running in the direction of 
the ileum, there is always a fascial 
fold, the fold of Treves. This is now 
picked up on the needle and carried 
over to the most dependent portion 
of the cecum, where it is fixed with a 
Lembert-Czerny suture and tied. 
This covers the stump of the appen¬ 
dix and completes the operation, re¬ 
quiring in all 5 or 6 minutes’ time. 
A. Walscheid (N. Y. Med. Jour., cvii, 
8, 1918). 

Reviewing the opinions of sur¬ 
geons on Lane’s theories as to the 
causation of intestinal stasis, and the 
results thereof, the writer concludes 
that although there is certainly an 
element of truth in Lane’s theories 
and practice, his operative pro¬ 
cedures were altogether too radical. 
In his opinion surgery of the large 
intestine must be limited, with few 
exceptions, to cases showing definite 
evidence of obstruction. Ileosig- 
moidostomy should be cast aside as 
an operation of election, resection 
being the ideal procedure. In fact 
Lane is said to have discarded ileo- 
sigmoidostomy in favor of resection. 
Side by side anastomoses are un¬ 
satisfactory, as demonstrated by the 
frequency with which diverticula de¬ 
veloped in the blind end. End-to-end 
anastomosis gives the most satisfac¬ 
tory results. G. L. McGuire (Trans. 
Can. Med. Assoc.; N. Y. Med. Jour., 
July 13, 1918). 

Colostomy.—Now and then it be¬ 
comes necessary to perform colostomy 


82 


ABDOMEN, SURGERY OF (MORRIS). 


for patients suffering from chronic ob¬ 
struction induced by a growth, stric¬ 
ture, angulation, adhesion, volvulus, 
invagination, foreign body, diver¬ 
ticulum, or enteroptosis, after other 
measures have been tried and failed. 
Again, an artificial anus is sometimes 
made to relieve patients suffering 
from membranous catarrh, the various 
types of ulcerative colitis and mul¬ 
tiple polypi, but this procedure is not 
so popular for this purpose as it was 
before the advent of appendicostomy 
and cecostomy. 

An artificial anus should never be 
made except as a dernier ressort be¬ 
cause of its unnatural location, the 
odors which emanate from it, the 
necessity of wearing a bandage, and, 
further, because a serious operation 
is required when the time for its 
closure arrives. 

An artificial anus may be tem¬ 
porary when made as a preliminary 
step to excision and resection or until 
such time as the condition, for the 
relief of which it was made, has been 
cured; or permanent, when the open¬ 
ing is to remain through life. 

It is not necessary to spend as 
much time in the formation of a tem¬ 
porary anus as it is in the making of 
a permanent anus, because the former 
is to be of short duration and the 
patient can bear the annoyance for a 
short time. In permanent colostomy 
it is of the utmost importance to pro¬ 
vide for the patient’s comfort by 
making the opening in such a way 
as to avoid painful evacuations, com¬ 
plete fecal incontinence or procidentia. 

Formerly there was considerable 
discussion as to which was the better 
procedure, inguinal or lumbar colos¬ 
tomy ; but lately the latter has fallen 
completely into disuse because the 


operation is more difficult, a suitable 
spur cannot be made, and the anus is 
situated where the patient cannot 
easily attend to it, while the former 
operation is devoid of all of these dis¬ 
advantages. 

Except where there are special 
reasons for doing otherwise, the 
colonic aperture should be made of 
fair size and as low down in the 
bowel as possible, because here the 
feces are more solid and give less 
trouble than when the anus is estab¬ 
lished at or near the cecum. An anal 
opening should never be made in the 
small bowel because when this is 
done there is a constant discharge of 
fluid through it, which annoys the 
patient and keeps the skin continually 
excoriated. 

The majority of surgeons concen¬ 
trate their efforts toward the forma¬ 
tion of a proper spur and the produc¬ 
tion of the double-barrel-gun effect, 
to prevent any of the feces from 
reaching the rectum, but do compara¬ 
tively little toward providing an anus 
over which the patient can exert a 
fair degree of control. 

Ganfs Colostomy .—The sigmoid is 
reached and isolated through a two- 
inch incision which crosses a line ex¬ 
tending from the umbilicus to the an¬ 
terior superior spine of the ileum, at 
the inner border of the oblique mus¬ 
cles ; working outward, the transver- 
salis is separated from the internal 
oblique muscle, with the index and 
middle fingers, for about one and one- 
half inches. The fingers are then forced 
upward through the oblique muscles 
and then over the external oblique 
and inward to the incision, separating 
the subcutaneous fat from the muscle. 
A loop of the sigmoid is now hooked 
up and then made to traverse the 


ABDOMEN, SURGERY OF (MORRIS). 


83 


route taken by the fingers, which 
makes it pass outward between the 
internal oblique and the transversalis 
muscles, and then through the in¬ 
ternal and external obliques and 
finally over the latter back to the 
incision. Again, when it is sutured 
after being made taut to avoid the 
possibility of subsequent procidentia, 
the angles of the wound are approxi¬ 
mated by two chromicized catgut 
sutures, which pass through the skin 
and fascia on one side of the incision 
and then beneath the longitudinal 
band of the sigmoid and out through 
the same structures on the other side, 
where they are tied. After the gut 
has been attached to the skin by a 
few plain catgut sutures it is sur¬ 
rounded by a bird’s nest dressing 
to prevent its being pressed upon, 
covered with rubber tissue lubricated 
with sterile vaselin to prevent stick¬ 
ing of the gauze to the bowel, and 
then the outer dressing and binder 
are applied. 

The intestine is not opened until 
after the third day, except when there 
is a marked distention; under such 
circumstances it is punctured at any 
time after six hours and amputated 
later. The projecting piece of gut is 
quickly and painlessly removed by 
injecting a small quantity of a one- 
eighth per cent, eucain solution into 
its mesentery. Cutting of the bowel 
proper causes no pain and does not 
require anesthetizing. 

By a few cuts of the scissors, the 
intestine is amputated about one- 
quarter of an inch from the skin, 
bleeding points are ligated en masse, 
and hemorrhage from oozing surfaces 
is controlled by hot-water compresses 
or the cautery. The raw edges left 
are encouraged to heal rapidly by the 


occasional application of 6 per cent, 
silver nitrate. When the obstruction 
is located above the sigmoid, the steps 
in the operation must necessarily be 
modified to meet the indications, but 
the changes in the technique will 
suggest themselves to the surgeon in 
individual cases. 

Patients have but little control 
over an artificial anus for the first 
few days, no matter what operation 
is performed, because the soreness of 
the wound and the irritability of the 
intestine excite frequent and strong 
peristalsis and the involuntary dis¬ 
charge of the feces. 

This procedure has the advantage 
over other colostomies in that but one 
incision is made and, further, because 
it gives the patient a more perfect 
control over the movements than do 
other colostomies. 

According to Gant, patients oper¬ 
ated upon in this way except during 
the first few days rarely complain 
of the involuntary escape of gas and 
ordinarily do not have an evacuation 
until they have taken a mild laxative 
or stimulated peristalsis by a small 
enema. 

It requires very little time to 
perform colostomy for a patient and 
the operation is practically devoid of 
danger, but the reverse obtains in the 
operation for its closure, as usually 
done by intestinal anastomosis. 

To avoid the dangers which accom¬ 
pany joining of the two ends of gut, 
Gant has devised a special plan for 
closing artificial ani. Some years ago 
he invented a clamp, which has 
proved useful in the closing of colos¬ 
tomy openings. Its weight is imper¬ 
ceptible to the patient, and when in 
place the shank, which is bent at an 
angle to the clamp, lies flat upon the 


ABDOMEN, SURGERY OF (MORRIS). 


84 ■ 

abdomen. The jaws are fenestrated, 
one-half inch broad and one and one- 
fourth inches in length. It is applied 
as follows: The clamp is placed in 
the applicator forceps, which are so 
adjusted that the jaws of the clamp 
remain open to the fullest extent. 
The parts having been cleansed, the 
partition between the upper and 
lower colostomy openings is stripped 
to dislodge any coil of the intestine 
which might otherwise be injured. 


The writer describes the following 
method calculated to insure sphincteric 
control after colostomy: The rectus 
is split vertically and the sigmoid is 
drawn out and divided at a convenient 
point. The lower segment is closed 
and replaced in the abdomen. The 
upper segment is made less bulky by 
removing the appendices epiploicjE and 
freeing it of mesenteric fat, but with¬ 
out in any way interfering with its 
blood-supply. The artificial sphincter 
is then made in the following manner: 
A loop of muscle-fibers is separated 



Operation for sphincter control after colostomy. (Ryall.) 
(ClinicalJournal.) 


The clamp is then applied, one blade 
in each opening, and pushed down 
sufficiently to include the entire spur, 
when it is released from the instru¬ 
ment. It is allowed to remain in situ 
until the spur is divided and it comes 
away unaided, which is usually from 
six to nine days later. The clamp 
causes slight soreness, but no acute 
pain. To avoid complications, the 
patient had best remain quietly in 
bed until it sloughs out. When the 
partition has been successfully de¬ 
stroyed the skin and edges of the 
opening are freshened under local 
anesthesia and closed with catgut or 
silk, and, in case there is considerable 
tension, the wound is supported by 
well-adjusted adhesive straps. 


from the posterior aspect of the rectus 
on either side of the wound. Each loop 
is then drawn over to the opposite side 
of the wound, so that one loop over¬ 
laps the other. The overlapping loops 
thus form a ring and through this 
the bowel segment is drawn. Sutures 
are then inserted to keep the muscle- 
fibers together above and below where 
the bowel comes through. Anchoring 
stitches are inserted through the skin 
and muscle inside to keep the bowel in 
position. The wound is then closed 
above and below the bowel, and the cut 
edges of the latter are sutured to the 
skin. A double sphincter is thus formed 
consisting of longitudinal and circular 
fibers. The longitudinal fibers are 
those of the anterior portion of the 
rectus, and the circular fibers are formed 
by the loops from the posterior part of 
the rectus. This operation can be 
modified by making double loops on 
each side and making them overlap one 





ABDOMEN, SURGERY OF (MORRIS). 


85 


another alternately. A similar opera¬ 
tion can be, and has been, carried 
through the external oblique, and like¬ 
wise can be done wherever the bowel 
is brought through muscle. A some¬ 
what similar operation can be per¬ 
formed for gastrostomy and appendicos- 
tomy. C. Ryall (Clinical Journal, Nov. 
11, 1908). 

Lilienthal’s Colostomy.—The for¬ 
mation of an artificial anus for the per¬ 
manent relief of obstruction of the 
lower bowel is regarded by most sur¬ 
geons as a loathsome makeshift for 
the prolongation of life. The mental 
picture of such an opening suggests the 
constant uncontrollable discharge of 
feces and flatus, the painful and an¬ 
noying dermatitis in the neighborhood 
of the exposed mucosa, and the neces¬ 
sity for constant change of dressings— 
in short, a condition of actual and per¬ 
manent disability for the ordinary 
duties and pleasures of life. 

For a number of years Lilienthal has 
been performing an operation which 
obviates nearly all the discomfort and 
filthiness of colostomy. The patients 
have absolute control of the bowels and 
can even hold a considerable quantity 
of fluid injected into the colon. The 
bowels move once or twice a day, the 
patient knows when the movements are 
about to occur, and—not by any means 
the least advantage—he is not annoyed 
by the necessity for wearing an appli¬ 
ance for obturation. The operation has 
been tested many times, and the pa¬ 
tients have been for the most part 
carefully followed up. A description 
of the steps of the operation follows:— 

An incision about 3% inches long, 
more or less, is made over the outer 
third of the left rectus muscle and par¬ 
allel with its fibers. The upper end of 
this incision is just about on a line be¬ 
tween the umbilicus and the left an¬ 


terior superior iliac spine, but the exact 
length and location of the wound de¬ 
pends somewhat on the amount of sub¬ 
cutaneous fat present. Through this 
incision the fingers explore the abdom¬ 
inal organs and the type and limitations 
of the stricture or tumor are learned. 
The sigmoid flexure, be it well devel¬ 
oped or not, is drawn out. As is well 
known, this part of the intestine varies 
greatly in length, but all is taken out 
which can be withdrawn without ten¬ 
sion. The two legs of the loop are 
separated as widely as possible, the 
upper leg being sutured to the perito¬ 
neum and posterior rectus sheath in the 
upper angle of the wound, and the 
lower is sutured in a similar manner to 
the inferior angle. Silk or linen thread 
is the suture material, and the stitch¬ 
ing is done by the continuous method, 
every third stitch being tied so as to 
avoid purse-stringing. The mesosig- 
moid is now sutured through and 
through to the peritoneum on each side 
(Fig. 1 in the annexed plates). 

At the lower leg of the loop the gut 
is doubly ligated very tightly with 
heavy silk or cotton twine. Section is 
carefully made between the ligatures, 
taking care to avoid soiling from the 
small amount of imprisoned intestinal 
contents. Pure carbolic acid on a gauze 
sponge is used to sterilize the mucosa. 
Chain ligatures of catgut or silk are 
now passed through the mesosigmoid 
so as to prevent hemorrhage, and this 
membrane is then cut across. We now 
have a short piece of sigmoid, the dis¬ 
tal leg of the loop in the lower angle 
of the wound, and a long piece sutured 
in the upper angle of the wound. The 
remainder of the mesosigmoid is cut 
away from the long piece of intestine, 
freeing it completely. The entire 
wound is now protected by gauze pack- 


86 


ABDOMEN, SURGERY OF '(MORRIS). 


ings, the peritoneum by our previous 
procedures being entirely closed ofif 
by suture. We should have about 3 or 
4 inches of free sigmoid at the upper 
angle of the wound. If there is more 
it should be ablated. Four equidistant 
clamps are now placed at the edge of 
this upper piece of intestine; the gloved 
finger is inserted into the lumen of the 
gut to the place where it is held to 
the peritoneum by suture; an assistant 
rotates the clamps so as to twist the 
gut around its longitudinal axis, after 
the manner described by Gersuny, 
from 180 to 360 degrees according to 
the texture and thickness of the walls 
of the sigmoid with which we are 
working. By withdrawing and rein¬ 
serting the finger from time to time 
the degree of constriction which this 
maneuver produces may be accurately 
gauged. When this seems to be suffi¬ 
cient for the purpose—a matter of in¬ 
dividual judgment—a few interrupted 
silk or linen sutures passed through 
the visceral peritoneum and sub¬ 
mucosa to the aponeurosis of the exter¬ 
nal oblique hold the rotated gut in 
position. It is now necessary to make 
sure by re-examination that a suffi¬ 
cient twist has been accomplished. If 
this seems satisfactory more sutures 
should be put in to hold the gut firmly 
to the aponeurosis. 

In examining with the finger now 
we find a double sphincter, the first 
one at the twist; the second, more an 
angulation than a sphincter, at the 
point of peritoneal fixation. A few 
chromic gut sutures close the portion 
of the remaining wound in the aponeu¬ 
rosis. The sphincteric action is main- 
taned by the fibers of the rectus 
muscle as well as by the twist in the 
intestine. A large-sized, rather stiff- 
walled rubber rectal tube, not a woven 


one, is now inserted about six inches 
into the intestine and is tied in place, a 
single light suture passing through its 
walls guarding against its accidental 
extrusion. The remainder of the 
wound is left open and packed with 
gauze while the tube is led off into a 
receptacle at the side of the bed. These 
wounds always become more or less 
infected, out I have encountered a true 
phlegmon only once and then a single 
incision sufficed for its drainage. 

About a week after the operation the 
tube may be withdrawn and the re¬ 
dundant sigmoid burned off with the 
actual cautery. Anesthesia is not nec¬ 
essary. Even then it will be found that 
repeated cauterizations will be re¬ 
quired during the course of the heal¬ 
ing in order to bring the intestinal 
mucosa to the skin level. Daily irri¬ 
gations through the tube should be 
practised so as to keep the patient’s 
bowels open. The string around the 
lower piece of intestine should be re¬ 
moved in three or four days; other¬ 
wise, there might be danger of com¬ 
plete and permanent closure, and it is 
necessary to maintain patency here 
for the sake of drainage. 

The control of the bowels is learned 
gradually by the patient, and he is as¬ 
sisted by a constipating diet and, for 
the first few weeks, small doses of 
deodorized tincture of opium and of 
subgallate of bismuth, 20 grains three 
to five times a day. It takes about a 
month for the final result to be at¬ 
tained, but the functional result in all 
uncomplicated cases will be found 
perfect. 

The writer employs one of the fol¬ 
lowing procedures: (1) Sigmoid 
above the stricture joined to the 
sound lower part of rectum; (2), if 
sigmoid fixed, transverse colon, if 
low, anastomosed to the rectum and 



The Dotted Line Shows Line of Section. The Blunt Retractor 
Holds Outer Third of Rectus Muscle Together with Skin 
and Aponeurosis. {Howard Lilienthal.) 

Annals of Surgery. 



Redundant Bowel and Mesocolon Cut Away. Twisting of the 
Intestine Begun. {Howard Lilienthal.) 

Annals of Surgery. 












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Twist Complete and Maintained in Position by Anchor Sutures 
Holding Sigmoid to Aponeurosis. {Howard Lilienthal.) 
Annals of Surgery, 



Operation Complete. Aponeurosis Further Stitched to Intestine 
and Wound Closed with the Exception of the 
Skin. {Howard Lilienthal.) 

Annals of Surgery. 












ABDOMEN, SURGERY OF (MORRIS). 


87 


to the descending colon above stric¬ 
ture; (3) cecum joined to rectum and 
the ileum to colon above stricture; 

(4) lowest coil of ileumjoined to the 
rectum and by a lateral anastomosis 
to the descending colon above the 
obstruction. 

In the upper opening the small 
female end of a Hildebrand button is 
inserted and fixed with a purse-string 
suture. With special forceps the 
larger male end is passed through 
the rectum and made to project up¬ 
ward, so that a small incision may be 
made over the central part, which 
then protrudes, allowing the bowel 
wall to slide down so close to the 
spring that no suture is needed. The 
2 halves of the button are then 
clamped. The result is a passage for 
fecal matter into the rectum instead 
of outward on the abdomen. McArdle 
(Pract., June, 1916). 

The indications for colostomy are 
given by the writer as follows: (1) 
As a preliminary to excision of the 
rectum for cancer. (2) To prolong 
life and prevent obstruction in inop¬ 
erable cancer of the lower bowel. 
(3) In all cases of pericolitis of the 
lower part of the pelvic colon where 
resection or short-circuiting is im¬ 
possible. (4) In some cases of in¬ 
tractable ulceration of the rectum. 

(5) In intractable fibrous stricture of- 
the rectum. (6) As a temporary 
measure in severe wounds of the 
rectum. 

Referring in particular to trans¬ 
verse colostomy, he points out cer¬ 
tain advantages of this procedure. It 
seems to afford better control over 
the stools than sigmoid colostomy, 
and prolapse is much less common. 
In performing transverse colostomy, 
the colon should not be opened at the 
most dependent part but as near the 
splenic flexure as is possible without 
causing tension. When the trans¬ 
verse colon is short, sigmoid colos¬ 
tomy should be preferred. The colon 
should subsequently be cut com¬ 
pletely in half to arrest the peristaltic 
wave at the opening. Lockhart- 
Mummery (Practitioner, Aug., 1917). 


Appendicostomy and Cecostomy.— 
These operations are useful in the 
treatment of disease located in the 
colon, but, when the disturbance lies 
within the small bowel or involves it 
and the large intestine, Gant’s cecos¬ 
tomy, which provides a means by 
which the treatment can be directly 
applied to both, should be substituted. 
It is frequently impossible to deter¬ 
mine whether the disease is limited 
to the colon or not, and because of 
this and the fact that this operation 
is no more difficult or dangerous than 
appendicostomy and ordinary cecos¬ 
tomy, and is equally effective both 
when the lesions are located in the 
small intestine, the large bowel or 
both, Gant believes his to be the most 
desirable procedure. 

Appendicostomy.—Some surgeons 
do not open the appendix during the 
operation because they fear infection. 
This practice, Gant believes, is bad 
except when it is obvious that the 
appendix is not obstructed, because 
he has encountered three failures fol¬ 
lowing it; in one the appendix was 
too short, in another it was strictured, 
and in still another it was blocked by 
an encysted grapeseed. 

He immediately amputates the ap¬ 
pendix and introduces the probe- 
pointed appendiceal irrigator, then 
nothing can interfere with postoper¬ 
ative irrigation, but when the appen¬ 
dix is diseased it is removed and 
cecostomy is performed. It is impor¬ 
tant that the irrigations be started at 
once when patients suffering from 
ulcerative colitis are despondent, 
greatly debilitated, have many move¬ 
ments, lose considerable blood, and 
suffer from insomnia and autointoxi¬ 
cation. 

To meet these conditions Gant has 


88 


ABDOMEN, SURGERY OF (MORRIS). 


devised a technique for appendicos- 
tomy which provides for irrigation 
both during and following the opera¬ 
tion, since the adoption of which his 
patients have gained very much more 
rapidly than formerly, when the ap¬ 
pendix was not opened for several 
days, during which time nothing was 
done to relieve them. Now and then 
a stitch abscess has occurred, but 
other complications have not arisen 
during or following the operation. 
Briefly described, the following are 
the steps: 1. The appendix is ap¬ 
proached through a gridiron incision 
and located by tracing the anterior 
longitudinal band downward, when it 
and the cecum are freed and brought 
outside. 2. The cecum is drawn first 
to one side and then the other by an 
assistant, while the parietal perito¬ 
neum is removed at the sides of the 
incision to insure union between it 
and the transversalis fascia, or the 
peritoneum is left intact when the 
gut is to be brought into contact with, 
it. 3. The appendix is freed and 
straightened by ligating and dividing 
adhesions and the mesentery at about 
one-fourth inch from it. 4. After the 
cecum has been scarified, two sero¬ 
muscular suspensory sutures are in¬ 
troduced on either side and near the 
base of the appendix, each taking 
three bites in the gut. 5. By means 
of a strong, long-handled needle, the 
anchoring stitches are in turn carried 
through the entire thickness of the 
abdomen and clamped with forceps, 
but when the intestine is joined 
directly to the peritoneum the bowel 
is anchored by chromicized gut su¬ 
tures, including the parietal perito¬ 
neum and transversalis fascia. 6. 
Having surrounded the appendix with 
gauze, a traction suture is introduced 


to steady it while it is being ampu¬ 
tated, cauterized, and probed. 7. A 
Gant appendiceal irrigator closed with 
a stopper is introduced and the ap¬ 
pendix ligated above it. 8. The ap¬ 
pendix is placed in the lower angle 
of the wound, pointing upward to 
prevent leakage later, and anchored 
by two seromuscular chromicized-gut 
sutures, which include the trans¬ 
versalis fascia. 9. The abdominal 
layers are then separately approxi¬ 
mated by interrupted or continuous 
stitches, after which the cecal sus¬ 
pensory sutures are tied across rubber 
tubes. 10. The appendiceal irrigator 
is prevented from slipping out by the 
adjustment of adhesive straps or by 
means of attached pieces of tape 
which encircle the body. 11. In 
urgent cases from one to three pints 
of warm saline solution are imme¬ 
diately injected into the colon, when 
the stopper is introduced to prevent 
leakage. 12. The wound is sealed by 
means of cotton and collodion, and is 
protected further by split gauze pads 
which overlap each other when placed 
about the appendix. 13. The outer 
end of the irrigator is surrounded by 
twisted gauze strips to prevent pres¬ 
sure upon it when the outer dressings 
composed of gauze pads or cotton and 
a many-tailed binder are adjusted. 

In gastro-intestinal perforation fol¬ 
lowed by acute peritonitis, the writer 
noted that the nausea, vomiting, and 
cardiac and pulmonary symptoms 
due to paralysis of the intestine, 
cease after appendicostomy, normal 
peristalsis being, moreover, re-estab¬ 
lished. The fluid introduced through 
the appendix by the drop method is 
quickly absorbed and nothing need 
be given by mouth until normal con¬ 
ditions are restored in the intestine. 
After 12 hours, the fluid discharged by 
rectum is usually colored with bile. 


ABDOMEN, SURGERY OF (MORRIS). 


89 


showing intestinal paresis has been 
overcome. Appendicostomy does not 
prolong the major operation more 
than 2 or 3 minutes. The absorption 
of water prevents shock and causes 
rapid detoxication by washing out the 
large intestine; siphonage of the 
small bowel is also effected. The 
writer reports 10 cases, in 1 of which 
the bowel had been perforated in 8 
places by a bullet. Two patients had 
been run over. Most of the other 
cases were perforated gastric ulcers. 
The appendicostomy gave results not 
obtainable by any other procedure. 
J. Roux (Rev. med. de la Suisse Rom., 
XXXV, 814, 1915). 

Appendicostomy has the advantage 
over cecostomy in that there is no 
discharge of feces or gas. A woman 
who had suffered over 14 months 
from bloody diarrhea was sent to a 
hospital with a diagnosis of tubercu¬ 
losis of the intestines. An explora¬ 
tory laparotomy having disproved 
this, and colitis been found, appendic¬ 
ostomy was performed. Enemas of 
salt solution were then given by the 
drop method, and later drop enemas 
of 1 to 2 per cent, tannin solution 3 
times daily. There was prompt im¬ 
provement and after 2 months com¬ 
plete recovery. The drop enemas 
were continued by the patient her¬ 
self. After a recurrence from neglect 
the fistula was dilated with a laminaria 
tent and the treatment resumed. The 
patient then recovered completely. 
Hans Brossmann (Med. Klinik, Sept. 
1, 1921). 

Appendicocecostomy .—On a number 
of occasions Gant has been com¬ 
pelled to abandon appendicostomy 
for cecostomy because the appendix 
was too short, strictured, or blocked 
by a grapeseed which rendered it 
unfit for irrigating purposes or had 
sloughed off following appendicos¬ 
tomy. In each instance, after the 
appendix had been amputated or 
inverted, a catheter was introduced 
through the appendiceal stump or 


opening and fastened by a purse¬ 
string suture introduced at or near its 
base. The cecum was suspended and 
the rest of the operation performed 
as in appendicostomy. 

Two patients suffered from diar¬ 
rhea induced by ulcerative lesions in 
the colon. In these cases the catheter 
was introduced a short way into the 
cecum, providing for colonic irrigation. 

The others were afflicted with 
enterocolitis, and it was thought ad¬ 
visable to irrigate both the large and 
small intestines. This was accom¬ 
plished by guiding a catheter across 
the cecum through the ileocecal valve 
into the small bowel. This procedure 
is termed “appendicocecostomy.” 

The principal objections to this 
operation are (1) that a change of 
catheters is impossible because the 
appendiceal and ileocecal openings 
are nearly on the same level, and (2) 
because the appendiceal aperture is 
so small that two catheters of suffi¬ 
cient size cannot be introduced to 
provide for large and small bowel 
irrigation. 

Cecostomy.—Experience has dem¬ 
onstrated to Gant’s satisfaction that 
cecostomy is preferable to appendi¬ 
costomy in the direct treating of 
intestinal disease. A comparative 
study of the advantages of cecostomy 
and the disadvantages of appendicos¬ 
tomy, as enumerated below, will show 
why the former should take prefer¬ 
ence over the latter. 

The advantages of the cecostomy 
operation, and more especially the 
writer’s cecostomy, which provides a 
means of irrigating both the large 
and small intestine, are: 1. Owing 
to the fact that the cecum lies against 
the inner abdominal parietes, it can 
be easily anchored without angulating 


90 


ABDOMEN, SURGERY OF (MORRIS). 


or twisting the bowel. 2. Since the 
opening is opposite the ileocecal 
valve, a catheter can be introduced 
into the small bowel for irrigating 
purposes or the siphoning of its con¬ 
tents for examination. 3. The cecal 
opening can invariably be made of a 
suitable size. 4. The circular, valve¬ 
like projection formed around the 
catheter by the infolding purse-string 
sutures prevents leakage. 5. The 
catheter can be changed without diffi¬ 
culty. 6. Closure of the opening fol¬ 
lows withdrawal of the catheter and 
a few applications of the copper stick 
or cautery. 7. Owing to the natural 
position of the cecum, there is less 
tension and pain following its anchor¬ 
age to the abdomen than occurs after 
appendicostomy. 8. This cecostomy 
may be employed in the treatment of 
lesions located anywhere in the intes¬ 
tinal canal, while appendicostomy is 
limited to those in the colon. 

The disadvantages of appendicos¬ 
tomy are the following: 1. The ap¬ 
pendix is more difficult to bring up 
for anchorage than the cecum because 
of its deeper and more uncertain 
position, and because it is frequently 
bound down by adhesions or a short 
mesentery. 2. Anchoring of the ap¬ 
pendix causes angulation or twisting 
of the cecum, which, in turn, may 
induce constipation, discomfort, or 
pain. 3. When the cecum about the 
appendiceal base is caught in the 
wound, it induces nausea and vomit¬ 
ing until detached (writer’s case).' 4. 
When the appendix is small, short, 
strictured, bound down by adhesions, 
blocked, or is otherwise diseased, it is 
useless for irrigating purposes. 5. 
Irrigation is frequently difficult and 
unsatisfactory because of the small 
appendiceal opening. 6. Pain follow¬ 


ing appendicostomy is much greater 
than after cecostomy owing to the 
pulling upon the appendix by the 
loaded cecum, the periappendiceal 
adhesions, or the squeezing of the 
attached mesentery when the wound 
is closed tightly about it. 7. Fre¬ 
quent dilatation or the insertion of a 
catheter is often necessary to keep 
the opening sufficiently large. 8. 
Death has followed injection of the 
irrigating fluid into the abdomen 
beside the appendix where an interne 
mistook an opening in the wound for 
that of the appendix. 9. After a cure 
it is more difficult to close the ap¬ 
pendiceal than the cecal outlet, and 
frequently appendectomy is impera¬ 
tive. 10. Appendicostomy frequently 
fails because the appendix slips back 
into the abdomen or retracts suffi¬ 
ciently to make irrigation almost or 
quite impossible. 11. The appendix 
has been known to slough off on 
several occasions owing to tension, its 
constriction by the sutures or destruc¬ 
tion of its blood-supply making subse¬ 
quent cecostomy necessary. 12. Appen¬ 
dicostomy is not effective when the 
disease is located in the small intes¬ 
tine. 13. Appendicitis requiring ap¬ 
pendectomy following closure of the 
appendiceal outlet has occurred. 14. 
Owing to the irritation caused by the 
catheter or treatment the mucosa may 
become so inflamed and swollen, 
ulcerated or strictured, that irrigation 
must be abandoned. 15. Finally, ac¬ 
cording to Reed, the catheter causes 
the wall of the appendix frequently 
to perish in a few days. 

Cecostomy with an Arrangement for 
Irrigating both the Small Intestine and 
Colon. —Gant has described what he 
believes to be an original way of irri¬ 
gating both the small and large bowel 


ABDOMEN, SURGERY OF (MORRIS). 


91 


through the same opening in the 
cecum—an operation which, for want 
of a better name, he has designated 
“cecostomy with an arrangement for 
irrigating both the small intestine 
and colon.” 

He believes his cecostomy is su¬ 
perior because the technique is 
simple, the operation requires no 
more time than others, there is less 
leakage owing to the purse-string 
infolding being substituted for his 
lateral sutures, both the small and 
large bowel can be irrigated by the 
attendant or patient, a firmer support 
is obtained by attaching the cecum 
to the transversalis fascia than to the 
parietal peritoneum, and the opening 
heals spontaneously after the cathe¬ 
ters are removed. 

Briefly described, the steps in 
Gant’s cecostomy are: 1. Through 
a two-inch intermuscular incision 
made directly over the cecum, it and 
the lowermost part of the ileum are 
withdrawn and the edges of the 
wound covered with gauze hand¬ 
kerchiefs. 2. The anterior surface of 
the cecum is scarified after the as¬ 
cending colon and ileum have been 
clamped to prevent soiling of the 
wound when the bowel is opened. 3. 
Four linen seromuscular purse-string 
sutures are introduced into the an¬ 
terior wall of the cecum opposite the 
ileocecal valve, and the bowel is 
opened inside the suture line. 4. The 
gut is grasped at the juncture of the 
large and small intestines and held in 
such a way that the ileocecal valve 
rests between the thumb and fingers 
of the left hand. A Gant catheter 
guide is then passed directly across 
the cecum and through the ileocecal 
valve into the small intestine, aided 
by the thumb and fingers. 5. The 


guide is held by an assistant while 
the obturator is removed and a cathe¬ 
ter is introduced into the small bowel. 
It is then removed and the catheter 
firmly held in the small gut by an 
assistant until anchored to the cecum 
by catgut sutures to prevent its slip¬ 
ping out during the operation. 6. A 
short rubber tube three inches long 
is projected into the cecum for an 
inch or more and anchored beside the 
one in the small gut. 7. The infold¬ 
ing purse-string sutures are now tied, 
forming a cone-shaped valve above 
the catheters to prevent leakage of 
gas and feces. 8. After removal of 
the clamps, the cecum is scarified and 
anchored to the transversalis fascia, 
denuded of its peritoneum by through- 
and-through suspension sutures of 
linen, or by chromicized catgut 
stitches, including the fascia, when 
the two peritoneal surfaces are to be 
approximated. 9. The wound is 
closed by the layer method and the 
catheters are fastened by stitching or 
by encircling them with an adhesive 
strip to hold them together, and 
crossing this at a right angle with a 
second piece of plaster placed be¬ 
tween the catheter to prevent their 
slipping out. 10. The ends of the 
catheters are closed with cravat 
clamps to prevent leakage, and the 
operation is completed by applying 
the dressings above the projecting 
tubes. 

One catheter is left longer than the 
other or is identified in some way in 
order that the interne or nurse may 
know which is in the large and which 
in the small intestine when time for 
irrigation arrives. To avoid danger 
from infection treatment is not begun 
before the fifth day except when 
urgent. 


92 


ABDOMEN, SURGERY OF (MORRIS). 


The catheter may be readily 
changed by cutting the attached ad¬ 
hesive strips and withdrawing the 
one projecting into the cecum. Gant’s 
catheter guide is then passed over 
the other into the small intestine, 
where it is retained until the old tube 
has been removed and a new one in¬ 
troduced. A second piece of catheter 
is then placed in the cecum and both 
are prevented from slipping out by 
adjusting fresh adhesive straps after 
the manner already described. 

Before deciding upon the above 
technique Gant irrigated the small 
intestine by passing a glass or silver 
catheter through a cecal opening, past 
the ileocecal valve, into the small gut 
each time it was irrigated, but this 
practice was abandoned as impracti¬ 
cable because of the difficulty en¬ 
countered in locating and passing the 
valve, and, further, because the 
patient could not irrigate himself in 
this way. 

Gant has had no reason to suspect 
that peristalsis forced the catheter 
out of the small intestine into the 
cecum except in one of his first 
cecostomies, where the tube was cut 
short and projected only one inch 
beyond the ileocecal valve instead of 
several, as it should. He feels confi¬ 
dent that the catheter remained in 
the small gut in his other cases be¬ 
cause (a) water injected through the 
colonic pipe was evacuated much 
quicker than when it was deposited 
in the small bowel; (b) when a 
minute quantity of a 10 per cent, 
solution of methylene-blue was in¬ 
jected through the former, it appeared 
in the urine more quickly than when 
introduced through the catheter in 
the small gut, and (c) the catheter 
guide could be carried over the tube 


in the small intestine and the latter 
could be removed and replaced with 
a new one at will, and, further, (d) 
fluid feces could be withdrawn more 
quickly and frequently through the 
pipe in the small intestine than 
through the colonic catheter. 

To avoid possible expulsion of the 
catheter from the ileum, catheters 
made of silk, silver, glass, and soft 
rubber reinforced by an inner metal 
tubing which cannot be forced out of 
the bowel owing to their non-flexi¬ 
bility are employed. Only that 
portion of the latter projecting into 
the small bowel was reinforced, and 
as a result it served the desired pur¬ 
pose and caused but little irritation 
because it was soft and flexible. This 
cecostomy permits the attendant or 
the patient to irrigate the small and 
large intestines at will, and the fluid 
may be siphoned or allowed to escape 
through the anus and the catheter 
can be changed quickly as often as is 
necessary. 

Enterocolonic Irrigator .—An instru¬ 
ment successfully employed by Gant 
a number of times in direct treatment 
of intestinal affections involving both 
the large and small intestines. It is 
made both of rubber and metal. 

When it is in position, the attached 
inflating bag lies in the small intes¬ 
tine at or near the ileocecal valve, and 
when distended prevents the escape 
of the solution into the cecum, there¬ 
by enabling the attendant to accu¬ 
rately gauge the amount of fluid 
deposited in the small bowel and to 
retain it there as long as required. 
By means of this twin-tube irrigator, 
the small and large intestines can be 
quickly and scientifically flushed, 
singly or together, by the physician, 
nurse, or patient. 


ABDOMEN, SURGERY OF (MORRIS). 


93 


The steps in cecostomy, when the 
irrigator is employed, are similar to 
those already described when separate 
catheters are used, except that the 
Gant catheter guide is unnecessary 
and the apparatus is retained in posi¬ 
tion by attached pieces of tape which 
encircle the body. 

Indications for Direct Bowel Treat¬ 
ment .—This form of treatment has a 
wide field of usefulness. Most physi¬ 
cians and surgeons appear to labor 
under the impression that it is limited 
to the colon and is indicated only in 
ulcerative lesions of the large bowel 
causing diarrhea. 

Gant has called attention to the 
fact that this type of cecostomy is 
indicated in the treatment of intesti¬ 
nal parasites, enteritis, enterocolitis, 
and catarrhal, tuberculous, syphilitic, 
dysenteric and gonorrheal colitis; 
ordinary and pernicious anemia; the 
many manifestations dependent upon 
intestinal autointoxication, ptomain 
poisoning, diarrhea of adults and 
children, intestinal feeding, malnutri¬ 
tion, and following operations upon 
the mouth, throat, esophagus or 
stomach; in gastric stricture, ulcer, 
cancer and other disturbances where 
refet of the organ is indicated. Gant 
also called attention to the fact that 
by means of his cecostomy various 
intestinal diseases could be investi¬ 
gated, and that the procedure could 
be used to determine the amount and 
nature of the intestinal juices and dis¬ 
charges, the character of the feces, 
the action of salines and other cathar¬ 
tics injected directly into the small 
and large bowel, and the marked im¬ 
mediate vasomotor effect following 
hot and cold enteroclysis and many 
other interesting problems. 

Gant has also pointed out the use¬ 


fulness of appendicostomy and cecos¬ 
tomy as a means of drainage when 
the cecum or other part of the colon 
was excluded. He has also employed 
appendicostomy and cecostomy a 
number of times when operating for 
mechanical constipation where colitis 
was a complication, and also in the 
palliative treatment of obstipation 
where the patient declined to have 
the cause of the obstruction removed 
and yet suffered from marked autoin¬ 
toxication or recurring impaction. 

Gant and Reed have also performed 
cecostomy once for the relief of septic 
peritonitis. The latter recorded a 
case of “defective flora” of the colon 
which was improved by the injection 
of the needed bacteria through a 
cecostomy opening, and called atten¬ 
tion to its usefulness in the treatment 
of intussusception. 

Following direct treatment, the 
condition of the patient becomes 
rapidly better and manifestations 
such as anemia and those induced by 
autointoxication rapidly disappear, 
and in cases of diarrhea the frequency 
of the stools generally diminishes and 
the amount of blood, pus, and mucous 
passed becomes markedly less. 

The good results following the 
irrigating treatment are due mainly 
to the mechanical action of the fluid 
in cleansing and stimulating the 
ulcers and removing retained toxins, 
and not to its temperature or chemical 
contents. Solutions should always be 
employed at the bodily temperature 
or warmer because of their soothing 
effect upon the irritated bowel, and 
not cold or at a freezing point, as 
recommended by some authors, be¬ 
cause when injected ice cold they 
excite enterospasm and cause much 
unnecessary suffering. 


94 


ABDOMEN, SURGERY OF (MORRIS). 


Briefly stated, the most reliable, 
stimulating, and soothing remedies to 
employ are weak solutions of boric 
acid, quinine, formalin, hydrastis, 
krameria and soda, silver nitrate, and 
those of a soothing nature are kero¬ 
sene, liquid paraffin or olive oil, ac¬ 
cording to indications. The stimulat¬ 
ing solutions are used stronger when 
ulceration is extensive and the oils 
warm when the gut is irritable. 

Colectomy.—Excision of the colon 
is performed for malignant disease, 
including tuberculosis and gangrene, 
but in practice the operation, like 
colostomy, is confined to cecectomy 
and sigmoidectomy, unless the morbid 
process directly involves the trans¬ 
verse colon, vhere the hepatic or 
splenic flexure is usually the seat of 
the disease. 

Of late, colectomy more or less ex¬ 
tensive, has been practised for severe 
chronic intestinal stasis. 

In colectomy for stasis the chief 
object is first to separate the evolu¬ 
tionary adhesions from the mesen¬ 
tery, The outer peritoneal aspects 
of the mesenteries should be left 
smooth. The ileum is divided usually 
within a few inches of its termination. 
The longer the small bowel remain¬ 
ing, the greater the increase in weight 
after colectomy; in stout patients 
shortening of the small intestine is of 
material advantage. The pelvic colon 
is drawn up from the pelvis and 
grasped with forceps about 2 inches 
above the level of the pelvic brim, 
and the end of the ileum attached 
directly to the cut end of the pelvic 
colon. The innermost row of sutures 
perforates all the coats of the bowel, 
and is of the button-hole type, while 
the outer rows secure only the peri¬ 
toneal and muscular coats. Difficulty 
in anastomosis because of the differ¬ 
ence in caliber is met by arranging 
the sutures so that each picks up a 
correspondingly greater portion of 


the circumference of the pelvic colon 
than of the ileum. Finally, the cut 
edges of the mesentery of the ileum 
and pelvic colon are sutured together, 
care being taken to leave no raw sur¬ 
face, An esophageal tube is intro¬ 
duced through the rectum and ileo¬ 
colic junction. Lane (Brit. Jour, of 
Surg., Apr., 1915). 

Summarizing the final results of 
total colectomy for constipation: in 
only 6 of 12 cases operated could the 
result be considered entirely satisfac¬ 
tory. In all cases there was great 
improvement in the constipation for a 
time, to be followed in 4 by a gradual 
recurrence, though in some cases not 
as severe as before. In no case was 
there diarrhea of long standing, nor 
undue thirst. In 6 cases there was 
marked improvement in nutrition. 
On the whole, total colectomy is 
justifiable only in severe cases of ob¬ 
structive constipation. The colec¬ 
tomy should be limited to the ascend¬ 
ing colon and the middle of the 
transverse colon, with lateral anasto¬ 
mosis of the ileum into the transverse 
colon. J. G. Clark (Surg., Gynec. and 
Obstet., May, 1916).' 

In carefully selected patients with 
stasis who are toxic from their con¬ 
dition, the writer deems right-sided 
colectomy, with preservation of the 
omentum, justifiable. It gives as 
good results as general colectomy 
and has less primary and secondary 
danger. There is. great variation 'in 
the length and size of the human in¬ 
testine. The shortest, 8 feet, is the 
carnivorous type; the longest, 33 feet, 
the herbivorous type. End-to-end 
union of ileum to colon is a safe pro¬ 
cedure. The closed end of the large 
bowel, being incorporated into the 
wound and brought through the peri¬ 
toneum, into but not through the 
muscle, may be opened to serve as a 
gas vent should the necessity arise. 
In most cases constipation is im¬ 
proved, but the best results follow 
operations of necessity for tumor and 
obstruction. Among 262 resections 
of the large intestine for malignancy, 
54 per cent, of those who recovered 


ABDOMEN, SURGERY OF (MORRIS). 


95 


were alive after 5 years, and 67.5 per 
cent, after three years. Among 235 
cases in which the right half of the 
colon was resected for tumors, dis¬ 
ease and stasis, the operative mor¬ 
tality was 12.5 per cent. Mayo (Jour. 
Amer. Med. Assoc., Sept. 9, 1916). 

Right colectomy is followed by less 
unpleasant postoperative sequelae than 
total colectomy or ileosigmoidostomy, 
and is fully as satisfactory in reliev¬ 
ing stasis. Only such cases as have 
failed to be relieved by simpler 
measures are considered suitable for 
operation. 

In a postoperative X-ray study of 
9 cases made for the purpose of de¬ 
termining whether the absence of an 
ileocecal valve had any effect on the 
emptying of the small bowel, it was 
found that in no case was there any 
damming back in the ileum or any 
evidence of dilatation of this portion 
of the bowel. 

The operation consisted in the re¬ 
moval of the last few inches of the 
ileum, cecocolon, and about a third 
of the transverse colon. In his 
earliest cases, he did not remove as 
much of the transverse colon as he 
did later, and postoperative X-ray ex¬ 
amination shows redundancy and 
ptosis of this portion of the colon, 
although the functional result was 
perfect. P. P. Johnson (Boston Med. 
and Surg. Jour., clxxvi, 266, 1917). 

The writer performed 15 total 
colectomies for constipation, with 1 
death; and right colectomy for can¬ 
cer in 9 cases, with 2 deaths; for 
tuberculosis in 11 cases, with no 
deaths. For constipation a right 
hemicolectomy (the cecum, ascend¬ 
ing colon, and half of the transverse 
colon) is not so effective as a total 
colectomy. The operation only re¬ 
lieves more or less, in a proportion 
dependent on the condition of the 
other organs. 

In the older total colectomy, the 
omentum was sacrificed. The writer 
holds that the omentum must be pre¬ 
served. But a total colectomy leaves 
irremediable and persistent abdominal 
disturbances, and Pauchet after 10 


years’ experience now does a right 
colectomy with preservation of the 
whole omentum. V. Pauchet (Presse 
med.. Sept. 9, 1918). 

Series of 19 operations in which 
the right colon was excised for relief 
of symptoms which were attributed 
to blocking of feces in the cecum. The 
immediate result of the operation 
showed that it could be done without 
undue risk: 20 cases reported by 
Mayo, 12 by Johnson, and this series 
of 19, without a mortality. It is, 
however, too serious to be under¬ 
taken except for very definite condi¬ 
tions of incurable partial obstruction. 
The indications for excision are dila¬ 
tation of the cecum, extreme mobil¬ 
ity, presence of adhesions in patients 
unrelieved by any palliative treat¬ 
ment and whose symptoms lead to 
chronic invalidism. Brewster (An¬ 
nals of Surg., Aug., 1918). 

Cecectomy. —This operation, while 
so named, is by no means limited to 
the cecum, for it is usually necessary 
to remove either the ascending colon 
or a portion of ileum or of both intes¬ 
tines together, tience such interven¬ 
tion may be termed ileocolectomy, 
ascending colectomy, etc., according 
to the individual case. 

The incision is made in the middle 
line, unless the diagnosis has been 
made so well that the operator can 
incise directly over the growth. As 
in all similar cases, the gut is mobi¬ 
lized, brought out and walled off with 
gauze, while it is emptied and 
clamped or held empty by assistants’ 
fingers or tape. The technique differs 
little from that of enterectomy of the 
small bowel. The mesentery is tied 
off and then divided, the large bowel 
excised and the operation completed 
by restoring the continuity of the 
intestine. As the cecum and ap¬ 
pendix have been sacrificed, it is 
necessary to secure an anastomosis 


96 


ABDOMEN, SURGERY OF (MORRIS). 


between the ileum and transverse or 
'descending colon. 

An end-to-end anastomosis is hardly 
practicable because of the disparity 
in size between the small and large 
bowel. Hence a lateral anastomosis 
or an implantation is indicated, which 
may be made by suture or button. 
The technique is that usually pur¬ 
sued in all intestinal anastomoses. 

Lateral anastomoses are practi¬ 
cable when the ileum is to be united 
with the neighboring ascending colon. 

No attempt is made to provide for 
a cecal pouch or ileocecal valve, but 
the two ends are joined after the cut 
end of the colon has been closed. 

It is sometimes advisable to im¬ 
plant the ileum in the descending 
colon or sigmoid flexure (ileosigmoid- 
ostomy). This would be necessary ifi 
the ascending colon were sacrificed. 

Sigmoidectomy.—As the sigmoid 
flexure is a favorite seat for cancerous 
growths it is often necessary to 
excise this portion of the bowel. In 
some cases no attempt is made to 
restore the continuity of the bowel, 
but the operation is terminated by 
forming an artificial anus. If, how¬ 
ever, the sigmoid is movable and the 
tumor can be removed cleanly, an 
end-to-end anastomosis may be made. 
Even when the rectum needs removal 
with the sigmoid, operators have pre¬ 
ferred to draw down the sound intes¬ 
tine and suture it to the anal region. 

In transperitoneal sig-moidotomy 
the author seldom uses the exagger¬ 
ated Trendelenburg posture, and in 
old and adipose persons is especially 
cautious. The sigmoid is opened on 
the anterior longitudinal band and the 
tumor exposed, drawn through, and 
double clamped. The growth is re¬ 
moved with the cautery and the de¬ 
fect closed from the mucous side by 
continuous sutures of chromic catgut ^ 


after the method devised by Pilcher 
for the excision of hemorrhoids. It 
is covered on the peritoneal side with 
a few interrupted silk sutures. The 
incision in the sigmoid is then closed 
with continuous catgut and inter¬ 
rupted fine silk. A red rubber tube 
is now passed up into the sigmoid 
beyond the line of sutures and 
fastened with a catgut suture to the 
anus; this is left in situ for a few 
days to prevent gas pressure. The 
procedure described was found most 
efficient for growths similar to papil¬ 
loma. Mayo (Annals of Surg., July, 
1917). 

In performing a three-stage opera¬ 
tion for cancer of the sigmoid, the 
writer at the first operation draws the 
loop of bowel containing the growth 
out of the wound as far as possible 
and keeps it there by a glass rod 
passed through the mesocolon or by 
a couple of stitches. Delivery of the 
colon is often facilitated by division 
of the external mesocolon. A glass 
tube is tied into the loop above the 
growth either at the operation or 36 
hours later. After 10 days, the part 
of the loop external to the abdominal 
wall is cut off, generally without an 
anesthetic. There is no pain except 
some colic if the mesocolon is ligated. 
The final operation can be performed 
at any time after the wound has 
healed. In 2 out of 3 cases the writer 
made end-to-end anastomoses in the 
abdominal wall without opening the 
peritoneal cavity. P. Lockhart-Mum- 
mery (Proctol. and Gastroenterol., xi, 
80, 1917). 

SURGICAL AFFECTIONS OF 
THE PANCREAS.—These comprise 
inflammation, cancer, cysts and cal¬ 
culi. There are no typical operations 
for these afifections, or upon the pan¬ 
creas and its duct for any conditions. 

Acute Pancreatitis.—In this condi¬ 
tion the pancreatic juice escapes into 
the tissues of the pancreas and into 
the peritoneal cavity, and the effect 
of its irritating" influence is very de- 


ABDOMEN, SURGERY OF (MORRIS). 


structive. The reddish, purulent 
fluid in the vicinity can be removed 
by a drain, and tense parts of the 
pancreas can be scarified to allow 
some of the interstitial exudates of the 
pancreas to drain out. Drainage is 
essential after removing tumors, or 
after an injury to the pancreas in 
order to dispose of the irritating pan¬ 
creatic secretion. 

The escape of pancreatic secretion 
from an injured gland reduces living 
fat in this vicinity into its fatty acid 
and glycerin, due to a ferment in the 
pancreatic fluid. The glycerin is 
absorbed and the fatty acid which 
remains makes a combination with 
lime salts, with the eflfect of produc¬ 
ing small areas of dull white at points 
where the reaction has taken place. 

Acute pancreatitis should be the 
occasion for prompt abdominal sec¬ 
tion for the severe and fulminating 
symptoms usually present, and emer¬ 
gency laparotomy would in any case 
be required. If the patients have not 
died outright of collapse or peritoni¬ 
tis, the fat necrosis or some other 
secondary conditon will demand 
operation. 

In the ultra-acute and acute vari¬ 
eties of pancreatitis imrnediate opera¬ 
tion should be the rule, the prime 
object being early and adequate 
drainage. The best approach in this 
stage is by an anterior incision either 
through the gastrocolic omentum or 
the gastrohepatic ligament, depending 
on whether the stomach is situated 
high or low. The pancreas should be 
freely incised longitudinally, or num¬ 
erous blunt punctures made in its 
substance, thus giving vent to the 
blood, lymph, and obstructed secre¬ 
tions. Both gauze and tube drainage 
should be laid down to the surface 
of the organ and conducted to the 
surface through a sheet of rubber dam 
to minimize adhesions. The only ex¬ 


ceptions to the rule of immediate 
operation are severe shock and ob¬ 
vious improvement from the effects 
of the disease. 

In 13 operations for acute pan¬ 
creatitis, 3 cases resulted fatally; one 
of these was of the ultra-acute 
variety. Usually there is ample mar¬ 
gin of safety for the experienced ab¬ 
dominal surgeon also to open, empty, 
and drain the gall-bladder and com¬ 
mon duct if necessary. J. B. Deaver 
(Jour. Amer. Med. Assoc., Ixix, 434, 
1917). 

The pancreas may be reached either 
above or below the stomach, through 
a second incision into the omentum 
or mesocolon, after making a suitable 
external incision. A counteropening 
through the lumbar region may be 
necessary for drainage. If an abscess 
is still intact it should be opened 
wherever most accessible. The in¬ 
frequently, fatal character, and opera¬ 
tive mortality (chiefly unavoidable) 
do not justify us in devoting, much 
space to abscess of the pancreas, the 
treatment of which largely resolves 
itself into management of the second¬ 
ary conditions to which it gives rise. 
Shallow incisions followed by simple 
wick drainage carried to the pancreas 
certainly serve to remove poisonous 
exudates to advantage in some cases 
of acute pancreatitis, and even the 
simple use of wick drains without 
scarification of the pancreas is some¬ 
times followed by good results. We 
must leave room when draining to 
allow necrotic masses to escape. 

Pancreatitis is, with few exceptions, 
an infective disorder, propagated in 
the majority of instances from the 
duodenum and gall-bladder, usually 
by the way of the lymphatics. Acute 
pancreatitis is usually infection plus 
ferment activity, though it may be 
traumatic or clinical exceptionally. 
In operating for acute pancreatitis, 
the diagnosis of pancreatitis is a 
•7 


98 


ABDOMEN, SURGERY OF (MORRIS). 


clinical inference based on the fact 
that pancreatic disease is associated 
with biliary disease in from 10 to 30 
per cent, of all cases, that it is more 
often present with long-standing dis¬ 
ease and with common duct involve¬ 
ment than with purely cholecystic 
inflammations. 

Free drainage of the pancreas is a 
desideratum. The peritoneum over 
the organ should be scarified so that 
gauze drainage may be brought into 
direct contact with the surface. A 
large aspirating syringe will detect 
collections of fluid, and these should 
be opened freely. Peripancreatic col¬ 
lections sometimes form in the lesser 
sac and point in the left loin, where 
they may be evacuated. Abscesses 
presenting anteriorly rarely adhere to 
the parietal peritoneum, and must be 
evacuated transperitoneally, some¬ 
times by a two-stage operation. 
Resulting sinuses are occasionally 
troublesome, the effects of the fer¬ 
ments evidencing themselves in the 
irritation of the skin. A strict anti¬ 
diabetic diet and bland ointments to 
the skin are helpful. 

The treatment of chronic pancre¬ 
atitis is that of the disease of the 
biliary tract found, at operation. J. B. 
Deaver (Boston Med. and Surg. 
Jour., Feb. 8, 1917). 

In a series of 18 cases of acute pan¬ 
creatitis, gall-stones were found in 15. 
In 11 cases the gall-bladder was 
drained (with 3 deaths) and in 2 the 
gall-bladder and one common bile- 
duct were drained, both patients re¬ 
covering. In 4, the operation was 
limited to the pancreas; 3 of these 
patients recovered and 1 died. 

Too large an incision in the pan¬ 
creas presents the risk of hemorrhage 
difficult to control. Scarification of 
the peritoneum over it should be suf¬ 
ficient to permit the contact of gauze 
drainage with the surface. A few 
blunt punctures of the pancreas may 
be of value in opening up the ducts 
and providing an outlet for secretion. 
Drainage should be instituted by 
means of gauze and tubes. J. B. Dea¬ 
ver (Surg. Clin. No. Amer., i, 1, .1921). 


Cancer.—A radical operation for 
cancer of the pancreas is hardly to 
be considered, and the only palliative 
procedure recognized is done for the 
relief of obstruction of the intestine 
or bile-tract. 

Cysts.—As a rule these can only be 
dealt with by incision and drainage. 
In a few cases small encysted collec¬ 
tions of fluid affecting only a portion 
of the organ have been excised out¬ 
right. In a few other cases cysts 
have first been opened and drained 
and then excised as a subsequent 
stage of procedure. 

Case of a woman presenting a very 
tender and immovable tumor in the 
lower epigastric and upper umbilical 
regions. Operation revealed the 
stomach, gastrocolic omentum and 
transverse colon flattened out over 
the mass and adherent to it. The tis¬ 
sues were all edematous. An ap¬ 
proach was made through the meso¬ 
colon and the cyst tapped, yielding 4 
quarts of viscid fluid. With the ex¬ 
ception of the head, the entire pan¬ 
creas was lying in the cyst; it 
was gelatinous in appearance. Two 
chromic catgut sutures were slipped 
around it, one at the tail, the other 
at the neck, and about three-fourths 
of it removed. The drainage tube 
continued to drain for 43 days. The 
patient left the hospital on the for¬ 
tieth day, practically well. J. T. 
Mason (N. W. Med., xvii, 24, 1918). 

Calculi.—When, as occasionally 
happens, the pancreatic duct is ob¬ 
structed by a calculus the condition 
cannot be diagnosticated readily, but 
is recognized when operating for 
some other condition, usually for 
gall-stones. A pancreatic calculus 
may sometimes be distinguished from 
a gall-stone with the fluoroscope. 
The indication is then the same as in 
obstruction of the common duct. 

One of the few surgeons who have 


99 


ABDOMEN, SURGERY OF (MORRIS). 


discussed typical pancreatic opera¬ 
tions is Villan, but it is not easy to 
determine what, if any, portion of the 
work he describes has been done on 
the living human being. For those 
interested we append a synopsis of 
his work. 

The term pancreatotomy is applied 
to incision of any portion of the organ 
or its surrounding tissues, for any 
purpose. If followed by suture it is 
termed -pancreatorrhaphy. Pancrea- 
tostomy or fistulation of the pancreas 
is simply pancreatotomy with drain¬ 
age, and is a frequent procedure in 
the surgical treatment of cysts, 
abscesses, etc. Pancreatectomy, par¬ 
tial or total excision, is used chiefly 
in tumors of the organ (and in trau¬ 
matisms and connection). These 
operations will be considered else¬ 
where in detail. Pancreaticotomy, 
pancreaticostomy, and pancreatic an¬ 
astomoses will also be considered in 
detail. 

Pancreatectomy.—This is neces¬ 
sarily partial. It has been done only 
to the extent of excising tumors. The 
tumor must first be freed from any 
attachment to neighboring organs as 
well as from the pancreas itself. The 
excision of the tail of the pancreas is 
attended with much less danger. The 
tumors here are more likely to be 
pedunculated. Median laparotomy is 
followed by liberation of the tumor, 
traction and application of strong 
forceps or ligatures, which prevent 
the entry of blood and pancreatic 
juice into the peritoneal cavity. The 
pedicle is then divided and cut and 
sutured, peritoneum sutured, and 
wound closed. It is often prudent to 
tampon and drain. Excision of the 
head of the pancreas is difficult and 
dangerous. Either a part or the 


whole may require removal. The 
tumor is detached with scissors and 
bleeding vessels ligated. The ducts 
of Wirsung and Santorini should be 
left intact, although the preservation 
of either one will suffice. 

If Wirsung’s duct should be 
divided it is usually sutured, and the 
same is true of the common bile-duct 
should it be injured, although at¬ 
mospheric pressure will sometimes 
serve to restore continuity of wound 
margins well enough. The operation 
is finished by suturing the remains of 
the pancreas to the duodenum. 

If the entire head of the pancreas 
is to be extirpated, it is necessary 
first to ligate the pancreatic duodenal 
artery and the right gastroepiploic. 
The duodenum must not be separated 
from the superior mesenteric artery. 
Wirsung’s duct and the common duct 
must be kept intact when possible; 
otherwise they must be preserved' by 
anastomosis. 

The entire pancreas can hardly be 
excised as a routine procedure, al¬ 
though the operation may be suc¬ 
cessfully performed on animals and 
even man. It is followed by diabetes 
mellitus. 

Pancreaticotomy.—This operation 
consists in incising the pancreatic 
duct for calculi. The duct, as in 
the corresponding operation on the 
common bile-duct, may be approached 
directly or indirectly through the 
duodenum. 

Simple Pancreaticotomy .—After lap¬ 
arotomy and exploration, if a cal¬ 
culus is found therein, the canal is 
incised, and the concrements removed 
by forceps or other apparatus de¬ 
signed for the purpose. Suturing of 
the cut duct is not necessary. A 
fistula naturally remains (pancreati- 


100 


ABDOMEN, SURGERY OF (MORRIS). 


costomy), but has a tendency to close 
spontaneously. 

Transduodenal Pancreatic otomy .— 
The duodenum is lifted upward. In¬ 
cision should be made in the anterior 
portion, and while some surgeons 
advocate a transverse, others prefer 
a horizontal incision. The ampulla 
of Vater should now be located, and 
if a pancreatic stone is present the 
opening may be incised in order to 
extract it. Suture of the incision is 
not necessary. 

Cathetering of the pancreatic duct 
and crushing of large calculi are 
recent procedures in connection with 
this operation. 

Pancreaticostomy and pancreatico- 
enterostomy have been done very ex¬ 
tensively in animal experiment. In 
human surgery, incision of the pan¬ 
creatic duct with drainage has been 
practised, but the operation of pan- 
creaticoenterostomy, which conserves 
the pancreatic juice in the intestine, 
is much more rational, and in several 
instances anastomoses have been ef¬ 
fected between the canal of Wirsung 
and some part of the digestive tract 

The pancreaticoduodenal region is 
exposed as for pancreaticotomy. 
Sutures or Murphy’s button may be 
used. The dilated duct should be 
freed from adhesions and either 
grafted into the intestine or, what is 
preferable, a lateral anastomosis may 
be made. Pancreatic fluid coming in 
contact with the other tissues may 
cause local or distant necroses. 

SURGICAL AFFECTIONS OF 
THE SPLEEN.—Abscess.—Splenic 
and perisplenic abscess will in all 
likelihood end fatally unless some 
unusual path is taken by the burrow¬ 
ing pus. Incision and drainage is the 


usual procedure, but, if the spleen is 
freely movable or readily freed from 
adhesions, splenectomy may be the 
indication of choice. 

Cysts.—Simple and parasitic cysts 
of the spleen are best treated by inci¬ 
sion and drainage in the same way as 
we treat abscesses. If the spleen is 
not bound down by adhesions, the 
operation may be done more safely 
as a two-stage procedure, the first of 
which consists in suturing the cyst 
wall to the abdominal parietes with¬ 
out opening of the former, and wait¬ 
ing for forty-eight hours for the 
formation of protecting adhesions. 

Splenomegaly.—Enlarged spleen 
from whatever cause is usually left to 
medical resources, unless it becomes 
so large as to cause serious pressure 
symptoms, in which case removal of 
the spleen may become a necessity. 

Floating Spleen.—While spleno¬ 
pexy has been sometimes done for 
this condition, most operators prefer 
the more radical removal of the 
spleen because of the difficulty of 
holding this organ with sutures, due 
to its friable tissues. The spleen may 
be fixed through an incision made 
obliquely along the left costal margin 
to the quadratus lumborum muscle. 
The patient is placed in the abdominal 
position upon a pad or air cushion 
similar to that used for forcing the 
kidneys against the abdominal wall. 
The peritoneal surface of the spleen 
is scarified, and so is the correspond¬ 
ing peritoneum of the abdominal 
wall. Kangaroo-tendon interrupted 
sutures entered at the lowest margin 
of the spleen serve to fasten it nearly 
in normal position, and a packing of 
gauze with a protecting apron of gutta¬ 
percha tissue gives support until 
supporting adhesions have formed. 


ABDOMEN, SURGERY OF (MORRIS). 


101 


Rydygier, for fixing the spleen, makes 
an incision in the middle line of the 
abdomen high up, and forms a pocket 
in the parietal peritoneum through a 
transverse peritoneal incision, and then 
with the fingers forms a pouch, into 
which the lower half of the spleen 
fits. The spleen is secured in this 
pouch by a few points of suture. 

Neoplasms.—Solid tumors of all 
kinds and tuberculosis require early 
removal of the spleen. 

TYPICAL OPERATION OF 
THE SPLEEN.—Splenectomy.—The 
typical external incision is median 
in traumatic cases (not considered 
here), but in all others either the 
semilunar line or one following the 
costal arch at a distance of an inch 
or so gives better access to the 
pedicle. The next stage is purely 
exploratory and involves division of 
peritoneum and examination for ad¬ 
hesions. If there are no diaphrag¬ 
matic or pancreatic adhesions, it is 
usually possible to isolate the organ, 
although extensive ligation may be 
required. It is sometimes necessary 
to free the spleen from the pancreas 
by sacrificing a portion of the latter. 
The organ is then lifted out of the 
wound, and packed about with gauze. 
It must be remembered that the 
spleen is very easily wounded before 
it can be ligated off, and that profuse 
parenchymatous oozing will then 
delay the operation. As in other 
operations on abdominal viscera, 
traction on the pedicle may induce 
shock, because of the intimate con¬ 
nection with the solar plexus. 

The next stage consists in ligating 
the spleen vessels, which is accom¬ 
plished by tying off the splenorenal 
ligaments and gastrosplenic omentum 
and ligation of the vessels of the 


hilum. The latter is naturally the 
ideal choice, but the delay involved 
adds to the dangers of shock, and 
unless the patient is in sound condi¬ 
tion to withstand operation it may be 
advisable to transfix the pedicle in 
one or two planes according to its 
width, and ligate each by itself. It 
is well to have apparatus ready for 
intravenous infusion, which may be 
begun at any moment that danger 
from hemorrhage appears. 

The after-treatment calls for no 
special principles. When the danger 
from hemorrhage or sepsis appears to 
be slight, the external wound may be 
closed at once. 

In malaria and leukemia the results 
of splenectomy have been discourag¬ 
ing. In polycythemia, Banti’s dis¬ 
ease, and hemolytic jaundice, how¬ 
ever, they are more promising. T. 
Rovsing (Hospitalstidende, Feb. 21, 
1917). 

After splenectomy in 2 patients, the 
author found a tremendous bone mar¬ 
row stimulation immediately after op¬ 
eration, as evidenced by marked 
leucocytosis, increased nuclear red 
forms, and increase in the large 
mononuclears and transitionals. One 
year later the differential count was 
much the same, except for the in¬ 
crease in the lymphocytes and marked 
increase in the nucleated red cells. 
There must be a more essential fac¬ 
tor in the blood cell destruction than 
the spleen. The spleen seems to have 
a very definite relation to bone mar¬ 
row cell production, and has a most 
definite relation to the maturing of 
the red cells, especially in the destruc¬ 
tive metabolism of their nuclei. In 
the 2 patients, who returned after a 
definite remission, there was much 
greater evidence of hemolysis than 
before. Gilbert (Mich. State Med. 
Soc. Jour., Sept., 1917). 

In diseases of the spleen it is abso¬ 
lutely essential that the surgeon 
should realize that physical findings 
are of minor importance, and that a 


102 


ABDOMEN, SURGERY OF (MORRIS). 


correct diagnosis must depend on the 
clinician who in turn must in large 
part rely on the various laboratory 
findings and special diagnostic meth¬ 
ods. The surgeon adds his opinion as 
to the advisability of splenectomy, 
based on the condition of the patient 
and the probable benefits from the 
operation. 

The essential features in the opera¬ 
tion as performed in the Mayo Clinic 
are as follows: The accessory adhe¬ 
sions and gastrosplenic omentum are 
separated, divided, and ligated. The 
dislocation of the spleen can usually 
be accomplished by stripping the ad¬ 
hesions with the fingers. In a few 
cases it is necessary to divide adhe¬ 
sions between clamps. After the 
spleen has been displaced a large pack 
may be introduced into the space 
formerly occupied by it. This pack 
serves to support the organ, and if 
well placed and left undisturbed, will 
often obviate difficult ligations of 
veins of some size. The spleen is 
now carefully elevated, and tracted 
toward the midline. Unless accessory 
vessels are encountered along the 
posterior border of the pancreas, the 
pedicle is ligated. A very exact and 
safe method is first to carefully ex¬ 
pose and individualize the arterial and 
venous branches in the pedicle from 
the posterior aspect by dividing the 
fibrous investment of the pedicle. 
The successive division of each 
arterial and venous trunk beginning 
with the lateral vein on each side of 
the fan-shaped pedicle will permit a 
very useful mobilization of the spleen, 
so that the clamping of the central 
portion of the pedicle which usually 
contains the splenic artery or its 
largest branch, is very much favored. 
Usually torn veins can be ligated, but 
it may be necessary to leave the 
gauze pack in place for a few days. 

The difficulties of splenectomy de¬ 
pend to some extent on the condition 
present. In pernicious, anemia it is 
practically never attended by tech¬ 
nical difficulty. In hemolytic jaun¬ 
dice, it is usually without special risk, 
though the spleen is occasionally 


very large. Splenic anemia is most 
often associated with high operative 
risk, particularly in advanced stages, 
because of thrombotic changes in the 
splenic and accessory veins. The 
same is true in hepatic cirrhosis. In 
the less common diseases splenec¬ 
tomy has no special risks. In the 
cirrhotic and ascitic stage of splenic 
anemia, convalescence is protracted 
and uncertain. D. C. Balfour (Inter. 
Abst. of Surg., Jan., 1918). 

Splenectomy may be very difficult 
when the spleen is fixed to neighbor¬ 
ing organs by old, firm adhesions. 
Section of such adhesions occasion¬ 
ally results in fatal hemorrhage or 
may call for long manipulations pro¬ 
ducing shock. In such cases the 
writer decorticates the spleen, the 
plane of cleavage lying beneath the 
adhesions and between the thickened 
capsule and splenic tissue proper. By 
incising the capsule and inserting the 
fingers beneath it the spleen can be 
rapidly decorticated and freed. Pre¬ 
vious ligation or compression of the 
pedicle between clamps allows easy 
completion of the operation. 

A case is reported in which the 
hypertrophied spleen was removed by 
this method. The organ was sclerotic 
and adherent close to the diaphragm 
and the posterior abdominal wall. 
P. Lombard (Bull, et mem. Soc. de 
chir. de Par., xlvii, 826, 1921). 

SURGICAL DISEASES OF THE 
LIVER AND BILIARY PASS¬ 
AGES. —The chief occasion for sur¬ 
gical intervention in these localities 
is gall-stone disease and its numerous 
consequences, for the relief of which 
typical operations are required. Sur¬ 
gical affections of the liver proper, 
while numerous, are less frequent,- 
and for the most part are relieved by 
simple general procedures, as incision 
and drainage. 

Abscess of the Liver. —Here may 
be considered abscess of the liver 
proper, and suppurative pericystitis. 


ABDOMEN, SURGERY OF (MORRIS). 


103 


As soon as the diagnosis is made, the 
pus should be drawn off with an 
aspirating apparatus, and most sur¬ 
geons prefer to make an exploratory 
incision for this purpose. In some 
cases it may be necessary to excise 
one or more ribs and go through the 
pleura, in which case the operation 
should consist of two stages in order 
to allow protective adhesions to form. 
After the pus has been removed an 
incision should be made of such 
character as to insure complete drain¬ 
age, and the abscess cavity allowed 
to close. If much liver tissue has to 
be divided to expose the abscess 
cavity, it will be necessary to use the 
cautery for hemostasis. 

Subphrenic abscess may be con¬ 
sidered here, although it may occur 
on the left side and have no connec¬ 
tion with the liver. The general 
principles of operation here are the 
same as in abscess of the liver—ex¬ 
ploration, aspiration, and eventually 
incision and drainage. It may be 
necessary to go through the thoracic 
wall. 

Cysts of the Liver.—Hydatids 
should be extirpated if possible, the 
operation amounting to hepatectomy, 
which see. So radical a procedure is 
seldom carried out, and the usual inter¬ 
vention, both for hydatids and non- 
parasitic cysts, is incision and drain¬ 
age, with the possibility of going 
through the thoracic wall. The oper¬ 
ation may be done in two stages with 
an interval for the formation of ad¬ 
hesions, or it may be done in a single 
sitting, the cyst being sutured to the 
operation wound before incision. 

In echinococcus disease of the liver, 
pain does not form part of the clin¬ 
ical picture, but there may be an in¬ 
flammatory reaction with adhesions 
which bring" pain, and may even simu¬ 


late gall-stones. The pain is a warn¬ 
ing of infection. In one man of 38 
years, a catarrhal jaundice and appar¬ 
ent gall-stone colics compelled an op¬ 
eration, but no gall-stones could be 
found. The common bile duct was 
enlarged but was not opened. At a 
later operation, it was found full of 
hydatid cysts and a large cyst found 
in the liver was evacuated. In the 
differentiation from gall-stones, the 
shape of the enlarged liver, especially 
its anterior outline, is important. If 
the organ is not enlarged, differentia¬ 
tion may be difficult. A. Chauffard 
(Annales de Med., Paris, Nov.-Dee., 
1917). 

Neoplasms.—A single focus of pri¬ 
mary cancer may sometimes be 
removed by hepatectomy; sarcoma is 
inoperable. 

Cirrhosis.—This has been con¬ 
sidered under Ascites (Surgery of 
Peritoneum). 

Hepatoptosis.—Hepatopexy is done 
usually in conjunction with other 
operations. The liver is scarified or 
brushed on the cephalad surface, and 
one of several methods in addition for 
retaining it in situ are essayed. The 
author includes shortening of the sus¬ 
pensory ligament. 

Cholelithiasis.—Simple accumula¬ 
tion of gall-stones, apart from the 
complication and secondary mischief, 
demands surgical removal. The 
choice then lies between cholecystos- 
tomy and cholecystectomy. 

Peters'on found gall-stones in 135 
out of 1066 laparotomies for pelvic 
disease. Kelly found them in 14.5 
per cent, and in the Mayo Clinic they 
were present in 17.1 per cent, of 
uterine myomata. The reasons for 
this large percentage of gall-stones 
in pelvic diseases are: (a) the high 
average age; (b) the high percentage 
of patients who have borne children; 
(c) the proportion of uterine and 
ovarian neoplasms present. He ad¬ 
vocates a routine examination for 


104 


ABDOMEN, SURGERY OF (MORRIS). 


gall-stones unless there is some con¬ 
tra-indication. When stones are re¬ 
moved, from 85 to 90 per cent of the 
patients will have no further trouble; 
otherwise 30 per cent, will suffer 
from further gall-bladder symptoms. 
His conclusion is to remove the gall¬ 
stones at the first operation when it 
can be done with safety. J. M. Neff 
(Intern. Abst. of Surg., Jan., 1919). 

Cholecystitis.—When the gall-blad¬ 
der has become chronically inflamed, 
altered by disease and adhesions, it 
should be extirpated. Partial chole¬ 
cystectomy is not looked upon with 
favor. If the process is relatively 
mild, with the ducts free and intact, 
cholecystostomy may suffice, but, 
like the appendix, a gall-bladder, once 
infected is always infected. 

Obliteration of Bile-passages from 
Without.—This is most commonly 
due to cancer, but may be due 
to other tumors and inflammatory 
processes. The typical operation for 
obstruction from without is an 
anastomosis between gall-bladder 
and intestine (cholecystenterostomy). 
When this is contraindicated perma¬ 
nent drainage by a biliary fistula 
(cholecystostomy) is the only resort. 

TYPICAL OPERATIONS ON 
BILIARY PASSAGES AND 
LIVER.—These are few in number, 
viz., cystostomy, cystectomy, and cho- 
ledochotomy, cholecystenterostomy, 
excision of liver. Other operative 
procedures appear to necessitate only 
general principles, such as explora¬ 
tory laparotomy, evacuation of pus, 
etc. The typical operations on the 
biliary passages are performed for 
cholelithiasis, incidentally including 
chronic cholecystitis. 

In gall-bladder operations the 
writer incises the posterior sheath 
parallel with the tendinous fibers of 
the transversalis, i.e., nearly trans¬ 


versely. The level of incision is 
about an inch above the free end of 
the gall-bladder, a small opening be¬ 
ing first made for confirmation of the 
diagnosis with the finger. The in¬ 
cision can then be enlarged to the 
middle line and laterally. The trans¬ 
versalis (posterior sheath) can, with 
the gloved fingers, be separated from 
the internal oblique with ease. After 
the gall-bladder procedures the cut 
edges of the transversalis can be 
whipped together with catgut sutures 
under absolutely no tension. The 

support given by the uncut transver¬ 
salis renders tension stitches unnec¬ 
essary and facilitates closure of the 
anterior sheath and skin. McArthur 
(Surg., Gynec. and Obstet., Jan., 

1915). 

Dangers of delay in operating in 
gall-bladder cases emphasized. The 

condition may be divded into 

3 stages: (1) That of cholecystitis, 
occupying the 5 or 10 years preced¬ 
ing the operation, and which has 
hitherto been looked on with entirely 
too much indifference and compla¬ 
cence; (2) that in which stones are 
present but cause no complications 
in the ducts; (3) that of the terminal 
condition, e.g., empyema of the gall¬ 
bladder, gangrene, pancreatitis, etc. 
In the first stage the treatment indi¬ 
cated is cholecystectomy, which is 
followed by practically no recur¬ 
rences or secondary operations. The 
second stage cases should also be 
treated for the most part by chole¬ 
cystectomy. In the first stage the 
operative mortality is less than 1 
per cent., and in the second, 3 to 5 
per cent. No cholecystostomies 
should be done in the first two stages, 
except In emergency cases, where 
the patient is in a bad condition at 
the time. In the older, third stage pa¬ 
tients seen 20 or 30 years from the 
beginning of their trouble, drainage 
of bile Is likewise ineffectual, and 
cholecystostomy often does not re¬ 
sult in the removal of residual stones. 
W. Wayne Babcock (Trans. Amer. 
Med. Assoc.; N. Y. Med. Jour., June 
30, 1917). 


ABDOMEN, SURGERY OF (MORRIS). 


105 


Among 800 gall-bladder and other 
biliary cases coming under the writ¬ 
er’s observation since January, 1916, 
8.5 per cent. (70 cases) were secon¬ 
dary (there were also a few tertiary) 
operations. Of the recent series, 51 
patients were originally operated by 
other surgeons, the remaining 19 hav¬ 
ing been operated on by the writer. 
In 36 of the 51, recurrence took place 
after a cholecystostomy, and in 15 
after cholecystectomy. The longest 
interval between operations was 15 
years. The average interval between 
operations in this group was about 5 
years and 9 months, the average pe¬ 
riod of freedom from symptoms 
being about 2 years and 3 months. 
In his personal series it was found 
that in 8 cases the symptoms recurred 
after primary cholecystostomy, 1 af¬ 
ter choledochostomy, and 10 after 
cholecystectomy, or 1.3 per cent, af¬ 
ter removal »and 10 per cent, after 
drainage operation. The great vari¬ 
ance between recurrences after radi¬ 
cal surgery of the gall-bladder and 
those after conservative surgery 
shows that radical surgical treatment 
gives the greater prospect of a perma¬ 
nent cure. J. B. Deaver (Jour. Amer. 
Med. Assoc., Apr. 17, 1920). 

Simple Cystotomy.—The gall-blad¬ 
der, having been exposed, is incised 
between two toothed forceps, and the 
stones if present removed with finger 
or blunt curet, taking care to remove 
all possible concrements, some of 
which may lie close to or in the open¬ 
ing of the cystic duct. One finger 
should be applied along the bladder 
externally, to aid in localizing con¬ 
crements. Folds and diverticula 
resulting from cholecystitis may con¬ 
tain concrements. The cystic duct 
and common duct must be palpated 
and, if stones are contained therein, 
choledochotomy may be required. 
The author prefers amputation of the 
greater part of the gall-bladder as a 
rule, because it removes an infected 


structure and avoids the distress 
caused by the lower margin of the 
liver impinging upon a gall-bladder 
sutured to the abdominal wall. 

Cystosftomy.—Cystostomy with 
Drainage.—This* form of cystostomy 
is really then a partial cystectomy. 
The tube remains in position eight or 
ten days, the bile escaping freely. 
After the tube has been withdrawn, 
a little bile may escape up to a week 
or so longer. As a rule, these fistulse 
close spontaneously without trouble. 

Cholecystostomy now shows a 
higher mortality rate than a few 
years ago. This is because it is now 
done in extreme cases of severe gall¬ 
bladder infection with complications. 

Reoperations in gall-bladder dis¬ 
ease are necessitated by recurrence of 
stones or by the formation of ad¬ 
hesions or fistulae. Stones are much 
more common after cholecystostomy, 
but may be formed in the ducts after 
cholecystectomy. Adhesions of such 
a character as to necessitate reopera¬ 
tion because of pain or interference 
with the mobility of the stomach or 
intestines are formed usually in severe 
cases in which there is suppurative 
peritonitis and long-continued drain¬ 
age is necessary. In a given case, 
adhesions should not be more fre¬ 
quent or severe after removal of the 
gall-bladder than after drainage, pro¬ 
vided the removal is done carefully. 

Fistulae necessitating reoperation 
open from the gall-bladder or ducts 
into the small intestine, the colon, or 
the stomach. When the adhesions 
are very dense and extensive, gastro¬ 
enterostomy gives the best permanent 
relief. J. H. Branham (Amer. Jour. 
Obstet. and Gynec., i, 331, 1921). 

Cystectomy.—Surgeons have 
proved by experience that cystostomy 
had many drawbacks. It is the con¬ 
servative method, but leaves behind a 
diseased gall-bladder, which invites 
new surgical disorders. Adhesions 
which are invariably present cause 


106 


ABDOMEN, SURGERY OF (MORRIS). 


the organ to lose its mobility, thus 
increasing the liability to further in¬ 
fection. Cystectomy, an operation 
originally performed only on suspi¬ 
cion of cancer, has been the choice of 
the author for many years, the sug¬ 
gestion having come from Langen- 
beck’s discovery of the safety of 
extirpation of the organ originally, 
and this idea confirmed by many 
operators later. 

Excepting in cases of cancer the 
author prefers the same operation 
for cystectomy that he does for cys- 
tostomy, for the reason that the small 
portion of gall-bladder which is al¬ 
lowed to remain allows of easier 
fastening to the drainage tube, and 
lessens the annoyance of hemorrhage 
from the artery and vein of the cystic 
duct. 

Cholecystectomy should be the 
predominant operative procedure in 
biliary surgery. With the destruc¬ 
tion of the lining mucosa of the gall¬ 
bladder by violent disease, the neces¬ 
sity for cholecystectomy is less evi¬ 
dent, while the mortality of the oper¬ 
ation for violent infection in the 
debilitated is such that a safer op¬ 
eration should be substituted; there¬ 
fore drain for gangrene, extirpate for 
catarrh. Choledocho-duodenostomy is 
indicated in elderly debilitated pa¬ 
tients who have or have had jaundice, 
or the evidence of common duct ob¬ 
struction; who will not well bear a 
dochotomy, who may have over¬ 
looked or residual stones, or who 
have duct obstruction, as in inoper¬ 
able carcinoma or in certain cases of 
mucocele, not to be treated by chole¬ 
cystectomy. It is also to be con¬ 
sidered in the treatment of Hanot’s 
cirrhosis of the liver. The patients 
least able to withstand the shock of 
operation are those who have had 
prolonged external drainage of bile, 
jaundice, or acute septic choledo- 
chitis. The operative treatment 
should, if possible, antedate and pre¬ 


vent these complications. Excluding 
technical operative errors the mor¬ 
tality of biliary surgery comes largely 
from delayed and secondary opera¬ 
tions. W. Wayne Babcock (Can. 
Pract. and Rev., Aug., 1917). 

Gall-stone colic may be a persistent 
symptom even where no gall-stones 
can be found. Cholelithiasis should 
be operated upon as soon as the 
diagnosis is made. A diseased appen¬ 
dix, if allowed to remain, will con¬ 
tinue to distribute infection to the 
gall-bladder after simple drainage of 
the latter. 

As regards the relative indications 
for cholecystectomy and cholecysto- 
tomy, the author believes that the 
former should be performed under 
the following conditions: (1) Stones 
in the gall-bladder; (2) cholecystitis 
without stones; (3) gall-bladder wall 
disease;, (4) stones or other obstruc¬ 
tions in the cystic duct; (5) adhesions 
around the gall-bladder which inter¬ 
fere with its pumplike action; (6) the 
strawberry or papillomatous gall¬ 
bladder; (7) malignancy. Cholecys- 
totomy should be used: (1) In pan¬ 
creatitis with jaundice; (2) in the 
very old and feeble cases or with 
poor physical condition; (3) where 
the operation would be dangerous be¬ 
cause of inaccessibility of the gall¬ 
bladder. The appendix should be re¬ 
moved whenever there is the least 
suspicion that it is diseased. F. R. 
Benham (Annals of Surg., Oct., 1917). 

Technique .—The gall-bladder, hav¬ 
ing been exposed, is freed from adhe¬ 
sions and from the normal peritoneal 
reflection to the surface of the liver. 
The presence or absence of gall¬ 
stones in the bladder is only of inci¬ 
dental importance, because it is for 
infection of the gall-bladder that the 
operation is done. The freed gall¬ 
bladder can be handled very much as 
one would handle the appendix, and 
the operation from this stage on is 
somewhat similar. Any bile or con¬ 
cretions which are found in the lower 


ABDOMEN, SURGERY OF (MORRIS). 


107 


part of the gall-bladder or the cystic 
duct are stripped out with the fingers 
into the cavity of the gall-bladder 
proper, which remains unopened. The 
part which has been emptied by strip¬ 
ping with the fingers is then ligated 
or clamped with a pair of forceps to 
prevent the return of contents to the 
region of the operation. A longi¬ 
tudinal incision large enough to 
allow the entrance of a small soft- 
rubber catheter is then made below 
the clamp or ligature, and extending 
as far as or into the lumen of the 
cystic duct. The catheter is intro¬ 
duced into this opening and tied in 
place with a catgut suture piercing 
the wall of the cystic duct and cathe¬ 
ter alike. This avoids displacement 
caused by vomiting. The next step 
consists in tying another catgut 
suture snugly around the cystic duct 
or the lower portion of the gall¬ 
bladder so firmly as to cut off all 
circulation in the walls. The gall¬ 
bladder is then amputated between 
the clamp and ligature, and the lumen 
of the stump at the point of com¬ 
pression by the ligature may be steri¬ 
lized like the stump of the appendix, 
by brushing it with 95 per cent, car¬ 
bolic acid neutralized a moment later 
with alcohol. The catheter, acting 
as a drainage tube, is then left escap¬ 
ing from any convenient angle of the 
wound of the abdominal wall. In 
two or three days the constricting 
suture is usually absorbed and the 
flow of bile then begins through the 
tube, which can be removed at any 
time subsequently, because the suture 
of catgut fastening the catheter to 
the cystic duct is absorbed at the 
same time with the constricting 
suture. The advantage of this tech¬ 
nique is that peritoneal adhesions 


have had time to wall in the area of 
operation so that bile or septic fluid 
escaping from the region of the stump 
makes its way safely to the surface. 
Sometimes it is an advantage to split 
the catheter longitudinally through¬ 
out its entire length, and to lay a 
strand of gauze loosely in the cathe¬ 
ter because this gives us capillary 
attraction to help in guiding bile or 
septic fluid to the surface; and if the 
walls of the catheter are prevented 
from closing entirely, any blood or 
other fluid between the stump and 
the external incision is drawn out the 
same way by capillarity. 

Some surgeons do not consider 
partial excision as a typical operation. 
They state that cases occur in which 
the gall-bladder is so fragile that its 
liberation would be impossible, but 
such cases make a small part of the 
ones actually dealt with in practice, 
and practically the same principles 
can be observed. 

Cholecystectomy without drainage 
advised in simple gall-bladder infec¬ 
tion, as contact of the bile with the 
peritoneum readily induces adhesions. 
The writer uses a right rectus in¬ 
cision, curving toward the xiphoid at 
the upper end. An incision is made 
into the hepatoduodenal ligament, 
and the pelvis of the gall-bladder 
grasped and pulled upward while a 
right angle clamp seizes the cystic 
duct and artery. A ligature is now 
placed around the cystic duct close 
up to its junction with the common 
duct, a second ligature is placed 
around the cystic duct and artery and 
the two are cut, the gall-bladder be¬ 
ing dissected out from below upward. 
The stump of the cystic duct is se¬ 
cured in the ligament by means of a 
crown suture passing through both 
layers of peritoneum and around the 
stump. The raw surface is covered 
with peritoneum and the abdomen 
closed without drainage. 


108 


ABDOMEN, SURGERY OF (MORRIS). 


Among 549 operations there were 
398 cholecystostomies with a mortal¬ 
ity of 1.7 per cent, 107 cholecystec¬ 
tomies, 0.9 per cent, and 44 choledo- 
chotomies, 9.0 per cent. There were 
26 secondary operations, 21 following 
cholecystostomy and 5 choledocho- 
tomy. A. M. Willis (Jour. Amer. 
Med. Assoc., Dec. 8, 1917). 

Of 2027 biliary operations in 2 
years at the Mayo Clinic, 219 (10.8 
per cent) were secondary. Of these, 
120 were for the removal of gall¬ 
bladders which had been drained pre¬ 
viously. There was only an 0.8 per 
cent mortality, showing that the risk 
in the secondary operation is no 
greater than in the primary. In 109 
of the 219 operations, calculi were 
found either in the gall-bladder, the 
ducts, or in both; 153 patients had 
cholecystitis. Adhesions were espe¬ 
cially noted in 148 cases, and in 41 
there was a definite pancreatitis. 
Either a mucous or a biliary fistula 
was present in 37 cases. Seventeen 
of the 209 patients were definitely 
jaundiced. In 64 of the 219 cases 
both the primary and secondary op¬ 
erations had been performed in the 
Mayo Clinic. In 12 of these, the pri¬ 
mary operation was cholecystectomy. 
Judd and Harrington (Annals of 
Surg., Apr., 1918). 

In cholecystectomy, if adequate de¬ 
pendent drainage is not established 
through a counterincision at the bot¬ 
tom of Morrison’s pouch, then it 
must be ample through the abdomi¬ 
nal incision, so that by no chance 
will there be an accumulation of fluid 
at any one point which may be dis¬ 
persed by the respiratory movements. 
If the mucous membrane of the gall¬ 
bladder is gangrenous; if there is 
chronic infection of the gall-bladder; 
if there is a stone embedded in the 
cystic duct; if the wall of the cystic 
duct is thickened; or if the wall of 
the gall-bladder is thickened by scar 
tissue as a reaction to infection—then 
mere drainage of the gall-bladder will 
very frequently be followed by recur¬ 
rent obstruction and infection, and in 
these cases cholecystectomy is rec¬ 


ommended. On the other hand, if the 
gall-bladder has approximately nor¬ 
mal walls, and if the cystic duct is 
approximately normal, then no mat¬ 
ter what the size or the number of 
stones, if the operation is performed 
with due care there will be rarely if 
ever a postoperative^pathologic cycle. 
In cholecystectomy the gall-bladder 
should be exposed by an ample in¬ 
cision so that there is free access to 
the base of the gall-bladder; the free¬ 
ing of tissue should be made by 
sharp dissection, care being taken not 
to injure the liver even slightly. 

The entire gall-bladder should be 
freed from its attachment so that am¬ 
ple opportunity may be given for de¬ 
termining the exact place at which 
the gall-bladder ends and the cystic 
duct begins, the division being made 
just proximal to this point. 

In death from “liver shock” follow¬ 
ing operation, the common causes 
are ether anesthesia, suboxidation 
from deep and prolonged anesthesia, 
trauma, and low blood-pressure. The 
use of a local anesthetic coupled with 
light gas and oxygen anesthesia; 
minimum trauma, secured by an am¬ 
ple incision, by sharp knife dissection, 
and by as brief an operation as is 
consistent with good surgery; blood 
transfusion if the blood-pressure is 
low, and morphine in case of pain, 
obviate or minimize these causes. In 
addition, the activity of the liver cells 
is increased by the application of lo¬ 
cal heat and by abundant water. To 
this end large hot packs should be 
used and adequate water equilibrium 
established before and after opera¬ 
tion. Crile (N. Y. State Jour, of 
Med., Oct., 1920). 

Choledochotomy.—This operation 
comes into play when after cystec¬ 
tomy the common duct or the hepatic 
duct is found diseased or containing 
concrements. A wide external inci¬ 
sion is requisite when it is believed 
that this operation is indicated. Ex¬ 
posure may be difficult on account of 
the conformation of the thorax, or 


ABDOMEN, SURGERY OF (MORRIS). 


109 


when adiposity interferes. It may be 
necessary in such cases for an assist¬ 
ant to draw aside all the surrounding 
viscera widely with the hands, with 
gauze beneath the fingers. If adhe¬ 
sions are absent the common duct 
may be lifted into the field with the 
fingers or a pair of padded forceps. 
The peritoneal covering is slit. The 
large vessels—hepatic artery and 
portal vein—behind the biliary pas¬ 
sages are to be avoided. A small 
vessel running obliquely across these 
must be held aside or tied and 
divided. Two lymph-glands in this 
locality may be so enlarged and in¬ 
flamed as to simulate concrements. 
The common duct must now be 
examined for concrements and in¬ 
flammation. If concrements are pal¬ 
pable, the duct is opened between 
slipnooses or forceps. Bile will at 
once escape and must be caught up 
with gauze pledgets and the stones, 
if present, removed with small forceps 
or curets. 

As a rule, however, extensive ad¬ 
hesions are present, and the opera¬ 
tion is much more complicated. 
These adhesions must be separated 
as far as possible, and if the cystic 
duct has not already been opened it 
should be incised. If the object were 
not primarily to extirpate the gall¬ 
bladder, this should now be done and 
the cystic duct divided. The chole- 
dochus should next be sounded 
through the opening, the finger pal¬ 
pating the outside of the canal. If 
concrements are present, the cystic 
duct may be laid open slowly until 
the common duct is reached. By the 
aid of small curets and forceps, and 
palpation externally, small concre¬ 
ments may be extracted. If neces¬ 
sary the incision may be continued 


into the common duct as far as the 
duodenum. Extraction of stones 
from an inflamed or dilated chole- 
dochus requires the same precautions 
as in the case of the gall-bladder. 
That portion of the duct behind the 
duodenum is very difficult of access, 
unless the reflection of peritoneum 
from the duodenum is first cut away. 
In cases of this sort it has been neces¬ 
sary to enter the duodenum. 

The conservative method is to 
draw* the duodenum to one side after 
freeing the peritoneum, but this is 
believed by some to affect the nutri¬ 
tion of the latter unfavorably. A 
drainage tube is inserted into the 
choledochus, and the latter sutured 
up to the tube by most operators, but 
the author usually dispenses with 
sutures, excepting the single one for 
holding the tube in place, because 
the walls of the duct normally fall 
together well, and atmospheric pres¬ 
sure keeps the cut margins together 
as well as sutures would do it, unless 
much unusual injury has been caused 
by the operative work. 

Writing on drainage of the com¬ 
mon duct after cholecystectomy, 
the author considers that such drainage 
by way of the stump of the cystic 
duct is only a temporary procedure. 
When prolonged drainage of the com¬ 
mon duct is needed, he opens the 
common duct and introduces a T- 
shaped rubber drainage tube. He 
has a number of patients wearing 
these tubes. This form of drainage 
is introduced in certain cases of pan¬ 
creatic lymphangitis, and chronic in¬ 
terstitial and interacinar pancreatitis. 
Early drainage of the common duct 
by this method or by a cholecysto- 
duodenostomy is the only chance for 
the cure of pancreatic diabetes. 
Deaver (Annals of Surg., Apr., 1916). 

In operations on the biliary pass¬ 
ages the common duct should be 


no 


ABDOMEN, SURGERY OF (MORRIS). 


opened: (1) When there are many: 
small stones in the gall-bladder or 
the cystic duct; (2) when the com¬ 
mon duct is enlarged and its walls 
greatly thickened; (3) when chills, 
fever, and jaundice have been present 
before the operation. Eisendrath 
(Jour. Kans. Med. Soc., June, 1917). 

In some cases of new growth or 
injury, the damage to the hepatic duct 
may be such as to necessitate hepatico- 
duodenostomy. A slightly curved flap 
is dissected out of the duodenal wall, 
leaving an opening into the duodenum 
about 2 cm. in diameter. The flap is 
then approximated to the posterior 
and lateral aspects of the stump of 
the hepatic duct so as to permit muco- 
mucous union of the posterior half 
of the circumference of the duct. 
The remaining free margins of the 
opening are sutured to the liver cap¬ 
sule just above the end of the hepatic 
duct by continuous catgut sutures so 
that the opening in the duodenum not 
occupied by the end of the hepatic 
duct is effectually closed. D. C. Bal¬ 
four (Annals of Surg., Mar., 1921). 

Cholecystenterostomy.—A typical 
operation indicated is closure of the 
biliary passages from without. A 
long abdominal incision is required, 
oblique or angular, beginning at the 
ensiform cartilage and carried down 
through the right rectus muscle. 
The intestines are controlled by 
gauze. If gall-stones are present they 
are removed, and it must also be 
determined that suspected cancer of 
the pancreas is not a calculus in the 
pancreatic region. A choice of intes¬ 
tinal locality for anastomosis is then 
in order. 

The duodenum is the ideal region, 
but in practice a high jejunal anasto¬ 
mosis is often preferable. The gall¬ 
bladder is emptied upon gauze, and 
the apex seized with a clamp. A loop 
of jejunum is similarly held with the 
fingers. Both structures are opened 


to the extent of a finger-tip, as in 
gastroenterostomy, and the suture is 
also performed as in the latter. This 
locality may be fortified with omen¬ 
tum, if the operator wishes. 

The Murphy button is useful for 
this anastomosis and is used by many 
operators, but simple suture suffices 
for most cases. 

One must be quite sure that 
the cystic duct is competent be¬ 
fore attempting cholecystenteros¬ 
tomy. The gall-bladder should not 
be too seriously pathologic. Anas¬ 
tomosis with the colon is dangerous. 
Anastomosis with the duodenum 
above the ampulla of Vater, though 
more difficult than with the jejunum 
by the retocolic method, is ideal 
physiologically and is the method of 
choice in non-malignant conditions 
where a permanent stoma is consid¬ 
ered, i.e., in obstruction of the duct 
not removable by choledochotomy or 
stenosing injuries following chole¬ 
dochotomy. Anastomosis by the re- 
trocolic method with the jejunum 
should be adopted wherever anas¬ 
tomosis with the duodenum is impos¬ 
sible through adhesions or other 
causes, and is the method of election 
in all malignant conditions. By 
either method it is essential to estab¬ 
lish a liberal stoma. All added anas¬ 
tomoses are of doubtful utility. As 
in cholecystostomy or cholecystec¬ 
tomy, drainage of Morison’s pouch is 
essential, with the added precaution 
of not allowing the drain to come in 
contact with the suture line. H. A. 
Shaw (Intern. Jour, of Surg., Aug. 
and Sept., 1916). 

Excision of Liver; Hepatectomy.— 
Indicated in tumors chiefly, including 
cysts, and sometimes after trauma¬ 
tisms. When a pedicle is present or 
the mass occupies the margin of the 
liver, hepatectomy is very easily per¬ 
formed by the aid of ligation. 

According to Garre, extensive resections 
of the liver can be carried out with the 


ABDOMINAL INJURIES (LAPLACE). 


Ill 


most simple means. If care is taken not 
to stretch the vessels in cutting through 
the organ and not to pull them out, it is 
not difficult to apply hemostatic forceps 
and a ligature. The vessels cut obliquely 
have to be taken care of by circular suture. 
Compression suture of the wound in the 
liver and catgut suture of the surface are 
the safest means of hemostasis. It is best 
to press together two wounded surfaces of 
the liver by suture, and, whenever possible, 
to make a wedge-shaped resection placed in 
an approximately vertical direction in rela¬ 
tion to the margin of the organ. Editors. 

When this is impossible the mass 
IS removed step by step, followed by 
ligation of all bleeding vessels. It is 
often possible to ligate these in ad¬ 
vance of division with a needle armed 
with catgut. After extirpation it is 
in order to ligate all lumina of blood¬ 
vessels with the aid of a needle rather 
than with forceps, and then suture 
the liver with catgut. Buried sutures 
are undesirable for the liver, however, 
as blood and bile seep into them. 
Pressure may be brought to bear for 
controlling hemorrhage that is not 
from spouting vessels, in some cases. 
Pressure is obtained by carrying a 
long catgut ligature deeply through 
the wound in the liver, and fastening 
each end of catgut to a broad plate 
of sheet lead. If the entering end of 
catgut is first fastened to its respect¬ 
ive plate of lead, the emerging end of 
catgut can be tightened to any de¬ 
sirable extent before fastening it to 
the second lead plate. Ears fash¬ 
ioned on the lead plates can be bent 
over to hold the catgut ends, and silk 
strands fastened to the plates and led 
out of the wound serve for removing 
the plates eventually when the catgut 
is absorbed. More than one pair of 
plates may be used for an extensive 
liver wound. 

Robert T. Morris, M.D., 

New York. 


ABDOMINAL INJURIES.- 

Under this heading will be considered 
the broad field of injuries of external 
origin to which the abdomen and the 
abdominal viscera are liable. These 
include contusions, which are impor¬ 
tant mainly because of the lesions to 
which the intra-abdominal organs are 
exposed; non-penetrating wounds, in 
which the abdominal walls alone are 
injured, and penetrating wounds, in 
which the walls and the abdominal 
viscera are penetrated. 

CONTUSION OF THE ABDO¬ 
MEN. —S Y M P T O M S .—Whether 
caused by blows, kicks, spent bullets, 
the passage of heavy bodies—such as 
vehicles—over the abdomen, etc., the 
symptoms attending a contusion in 
this region are not always such as to 
call attention to the seriousness of 
the lesion present. The gravest ab¬ 
dominal injuries may coexist with 
practically no external or general in¬ 
dication of mischief, the patient walk¬ 
ing a long distance, perhaps, without 
experiencing anything more than 
slight local pain where the blow had 
been received. 

Although the abdominal walls may 
be but slightly injured, the lesions 
may consist of extensive extravasa¬ 
tions of blood between the layers, or 
sufficient laceration of the muscular 
and other tissues to give rise to more 
or less local sloughing. Such lesions 
of the abdominal wall, however, are 
not always accompanied by injury of 
the abdominal organs. 

Usually, in these cases, according 
to Scudder, the greater the force the 
greater the injury, but a trivial blow 
may result in serious damage to intra¬ 
abdominal viscera. A hollow organ, 
if distended, is more vulnerable than 
if empty. Inquiry should be made as 


112 


ABDOMINAL INJURIES (LAPLACE). 


to the last mealtime and as to the 
last micturition. The exact direction 
of the blow is important. The clothes 
of the patient sometimes offer some 
indication as to the injury. 

A trifling superficial injury of the 
abdominal wall may be associated 
with serious internal lesions, owing 
to the resistance offered by the ab¬ 
dominal walls and the fragility of the 
abdominal organs. The external ap¬ 
pearances, therefore, should not be 
taken as a criterion. 

From observations of some twenty 
cases of visceral injury, following 
contusion of the abdomen, verified by 
operation or autopsy by Brewer, the 
most prominent were pain, tender¬ 
ness and muscular rigidity, and like¬ 
wise the most reliable. The deep- 
seated, localized pain following injury, 
especially increased by pressure, and 
accompanying local or general mus¬ 
cular rigidity, is one of the most 
constant signs of intra-abdominal 
injury. Brewer holds that the asso¬ 
ciation of these three symptoms is 
almost pathognomonic of abdominal 
irritation. Pain, however, is often 
present, with tenderness, in injuries 
limited to the abdominal wall; but in 
these instances muscular rigidity is 
generally absent. In the absence of 
subcutaneous pain localized tender¬ 
ness with rigidity is strongly sug¬ 
gestive of visceral injury. Of the 
three symptoms, muscular rigidity is 
the most reliable, and sometimes the 
only sign. In the absence of other 
diseased conditions spasm of one or 
more of the abdominal muscles fol¬ 
lowing the traumatism may be looked 
upon as nature’s effort to protect an 
injured organ from further irritation. 
Vomiting is a symptom often present, 


but not always an accompaniment of 
severe visceral injury. It is com¬ 
monly present with involvement of 
the stomach and upper part of the 
intestinal tube, and with injuries 
resulting in severe shock. The signs 
of free fluid in the abdominal cavity 
are very suggestive. 

In most cases, however, severe 
contusions of the abdominal wall, 
whether the deep organs are involved 
or not, are followed by agonizing 
pain in the region of the injury, rest¬ 
lessness, nausea or vomiting, marked 
prostration (indicated by a small, 
rapid, and irregular pulse), pallor 
(sometimes attaining lividity), cold 
sweats, rigidity of the abdominal 
wall, meteorism, anxiety, and fear of 
a fatal issue. 

All these symptoms bear the im¬ 
print of a severe nervous commotion, 
and, if the extensive distribution of 
the sympathetic nervous system in 
the abdominal cavity is borne in 
mind, the fact will become evident 
that symptoms usually witnessed im¬ 
mediately after the receipt of the 
injury are due mainly to the influence 
of the concussion upon the sym¬ 
pathetic supply. Sudden death has 
been known to follow a violent blow, 
especially when received in the region 
of the solar plexus. 

The pain varies according to the 
location of the traumatism and the 
sensitiveness of the patient. Very 
severe at first, it usually becomes less 
marked after a few hours. It is 
greatly influenced by shock, profound 
prostration reducing its intensity by 
reducing sensation. Great restless¬ 
ness usually accompanies abdominal 
pain after injuries, as well as during 
other diseases, such as appendicitis, 


ABDOMINAL INJURIES (LAPLACE). 


113 


when the suffering is due to a local¬ 
ized trouble. The pain may be 
radiated in various directions,—the 
shoulder, the umbilicus, the left 
axilla, the testicles, etc.—according 
to the site of the primary lesion. 
Local tenderness is usually marked 
over the site of the traumatism. 

The vomiting varies greatly in 
intensity from mere nausea to the 
most violent expulsive efforts, which 
are liable, by the strain upon the 
abdominal organs, to suddenly in¬ 
crease the extent of the lesions. The 
vomited matter sometimes contains 
blood, especially if the upper portion 
of the digestive tract is involved in 
the injury. Constant and persistent 
vomiting tends to indicate a contu¬ 
sion accompanied by visceral lesions. 
According to Berndt, in simple cases 
the vomiting is repeated but two or 
three times. When the intestine is 
ruptured the vomiting is persistent 
and intractable and liver-dullness is 
absent. 

The degree of shock depends upon 
the nature and extent of the injury 
and especially upon the amount of 
blood lost. When the signs of col¬ 
lapse gradually become more marked, 
internal hemorrhage from rupture of 
one or more of the viscera is to be 
feared. 

The pulse, usually rapid and weak 
at first, gradually becomes stronger 
and slower if a favorable reaction is 
about to take place. If, on the con¬ 
trary, an unfavorable course is being 
taken and some complication is to 
occur, its rapidity and tension may 
become increased. Irregularity is 
not a favorable indication if it per¬ 
sists. Temperature is independent of 
the pulse, except when a favorable 
reaction is taking place, when it may 


return to the normal line after having 
gone beyond or below it. The usual 
belief that a subnormal temperature 
always follows internal hemorrhage 
is fallacious; for it may also be raised. 
The temperature, therefore, is of no 
value as a guide. 

Hematemesis may assist in estab¬ 
lishing the diagnosis of lesion in the 
stomach or the upper portion of the 
intestinal tract, while the presence of 
blood in the stools may do the same 
as regards lesions of the intestines as 
a whole, including the colon. But, 
in itself, this symptom is, by no 
means, characteristic, since a violent 
strain may cause sudden engorge¬ 
ment of pharyngeal, gastric, rectal, 
or hemorrhoidal vessels and then, 
several days after the accident, blood- 
rupture ensue. Even when present, 
streaks in vomited matter or stools 
are not always indicative of an alarm¬ 
ing condition. 

Blood in the urine is a more'reliable 
sign of lesion in the urinary tract, 
especially the kidney and bladder. 
Anuria is also indicative of lesions in 
these organs; but, as shock frequently 
arrests the flow of urine, it is only 
valuable as a symptom after all symp¬ 
toms of shock have passed. 

Hemorrhage into the orbits and 
from the ears are occasionally met 
with when the concussion has been 
very severe. This symptom does not 
necessarily indicate that the injury 
is an unusually dangerous one. 

A few hours after the accident the 
pain usually becomes reduced; the 
patient may be more quiet and, per¬ 
haps, somnolent, although the pulse 
remains in its former condition. This 
period lasts between twelve and 
twenty-four hours. If at the end of 
this time there be no complication, 
1-8 


114 


ABDOMINAL INJURIES (LAPLACE). 


a visceral lesion is probably not 
present. If, on the contrary, the 
symptoms gradually increase in in¬ 
tensity, the likelihood of grave injury 
is very great. 

In the light of present knowledge, 
however, the practitioner should not 
delay active procedures until the 
patient’s life becomes compromised 
by permitting the mechanical injury 
produced to start an infectious proc¬ 
ess, when the manner in which the 
injury was inflicted and the force ap¬ 
plied tend to suggest serious internal 
lesion. An exploratory incision is 
sometimes permissible (see colored 
plate). 

DIAGNOSIS. —In abdominal con¬ 
tusions the diagnosis should primarily 
be based upon the history of the acci¬ 
dent, the manner in which the injury 
occurred, the shape of the body, or 
bodies, by means of which the trau¬ 
matism was inflicted, and the degree 
of percussive force applied, and, 
secondarily, upon the symptoms 
present. 

The value of abdominal or bimanual 
vaginal examination of patients while in a 
hot bath has been emphasized by Carter. 
In many instances the abdominal relaxa¬ 
tion obtained is quite equal to that ob¬ 
tained under an anesthetic, with the added 
advantage that the patient can help the 
examiner by voluntary movements, such 
as deep inspiration, holding the breath, etc. 

Report of 2 cases of injury fol¬ 
lowed by a quiescent period. At oper¬ 
ation, the small intestine was found 
completely severed and the ends ot 
the intestine closed off by the local 
reflexes so that there was no leakage. 
After certain injuries to the abdomen 
there is frequently such a period of 
from 12 to 24 hours during which the 
surgeon and patient may decide what 
is to be done. Purgatives prove harm¬ 
ful. G. E. Armstrong (Jour. Amer. 
Med. Assoc., Dec. 6, 1919). 


Lesions of the Intestinal Tract.— 

Various theories have been advanced 
as to the manner in which rupture of 
the intestine is brought about, but 
experiments have shown that squeez¬ 
ing of the gut between the com¬ 
pressed abdominal wall and the verte¬ 
bral column is the main mechanical 
factor brought into action. 

In reporting a personal case of re- 
troperitoneal rupture of the duodenum 
in which the points of interest were 
slight general and local reaction from 
the resulting abscess, due to the rela¬ 
tive sterility of the duodenal con¬ 
tents, and also a point of tenderness 
beneath the twelfth rib, the writer 
reviews a series of 22 cases. The in¬ 
jury is peculiar to the active working 
male, and is always due to trauma. 
In the 22 cases, 82 per cent, were 
situated in the second or third 
portions of the duodenum, and 15 
showed retroperitoneal extravasations 
at operation. This is always found 
either in the root of the transverse 
mesocolon, in the root of the mesen¬ 
tery of the small bowel, or involving, 
in addition, the intervening retroperi¬ 
toneal space, and is usually of rapid 
formation. The contents is a bloody, 
bile-stained fluid mixed with gas that 
soon becomes purulent. The peri¬ 
toneal cavity is clean or at best con¬ 
tains a very small amount of free 
blood-stained fluid, probably from a 
minute injury to some viscus. Peri¬ 
tonitis is undoubtedly delayed for 
some time by the intact peritoneum, 
but ultimately occurs. There may ap¬ 
pear a fixed tumor in the upper right 
quadrant, but this was only noted in 
2 cases. Of the 22 cases, 20 were op¬ 
erated on and but 3 recovered. No 
case survived when operation was 
postponed longer than 24 hours. R. 
T. Miller (Annals of Surg., Ixiv, 550, 
1916). 

Injury to the bowel by direct vio¬ 
lence to the abdominal wall is pos¬ 
sible under the following conditions: 
First, when the force is sufficient to 
carry the abdominal wall back so 


ABDOMINAL INJURIES (LAPLACE). 


115 


that the bowel is caught between the 
object producing the force and the 
body of a lumbar vertebra. The posi¬ 
tion of the patient at the time of in¬ 
jury with the body inclined forward 
and a weak, flabby abdominal wall 
would predispose to this form of 
injury. A second possible condition 
in which rupture of the bowel might 
occur is when it is filled by a solid 
or semi-solid matter that offers suffi¬ 
cient resistance to rupture the gut 
before it can recede from the oncom¬ 
ing object producing the sudden 
blow. A third possible condition is 
that rupture may occur by reflex 
stimulation of the intestinal nerves 
through the nerve supply of the ab¬ 
dominal wall. 

Rigidity of the abdominal muscles, 
pain of a severe type, a strained and 
anxious countenance, a varying de¬ 
gree of shock, and a rapidly increas¬ 
ing pulse-rate are sufficient signs to 
lead to a diagnosis and to indicate 
immediate operation. J. S. Wright 
(Can. Med. Assoc. Jour., viii, 228, 
1918). 

Crushing against the ileum is rarely 
produced. Another, although rare, 
cause of rupture is the presence, in 
the intestinal tract, of liquid or semi¬ 
liquid material, the sudden circum¬ 
scribed pressure exerted upon the gut 
causing it to burst, through overdis¬ 
tention. The small intestine is the 
seat of lesion in 75 per cent, of the 
cases of rupture in the course of the 
intestinal canal. Hence the impor¬ 
tance of carefully ascertaining in 
each case the direction from which 
the percussive force came, the inten¬ 
sity of that force, and the relative 
position of the organs between the 
site of pressure and the spinal 
column. 

Another factor of importance in es¬ 
tablishing a diagnosis is the size of 
the instrument causing the injury. 
Lesions of the digestive canal, for 


instance, are usually the result of 
violent and sudden percussion pro¬ 
duced by a body over a limited sur¬ 
face of the abdominal wall. 

The predisposing factors are the 
presence of solid, semisolid, or fluid 
matter in the hollow viscera; lean¬ 
ness of the individual, and intestinal 
adhesions. 

Any of the above accidental causes 
of injury being fulfilled, rupture of 
some portion of the gastrointestinal 
tract is likely, especially if there is 
loss of consciousness at the time of 
the accident, followed by collapse, 
severe pain, a rapid and weak pulse, 
vomiting, tympanites due to the 
escape of intestinal gas into the ab¬ 
dominal cavity, and tenderness and 
rigidity of the abdominal walls. 

Frankel has laid great stress on the 
slow rise of the temperature from 
hour to hour. A pulse above 100, if 
hemorrhage can be excluded, speaks 
in favor of rupture of the intestines 
and incipient peritonitis. 

Case of rupture of the jejunum in 
a boy who was struck in the abdomen 
while playing football. The main 
symptoms were vomiting, elevation 
of temperature to 101° F. (38.3° C.), 
pulse 118 within a few hours after the 
accident, some rigidity of the upper 
abdomen, but marked absence of 
shock and severe pain. Twenty-eight 
hours after injury the pulse was 112; 
the temperature, 100.5° F. (38° C.), 
the leucocytes, 25,000. Vomiting had 
occurred 5 times, the last vomitus 
having a fecal odor. The bowels had 
acted once; there was slight tympa¬ 
nites. Operation revealed a large 
rent in jejunum. Suture with drain¬ 
age of the abdominal cavity was fol¬ 
lowed by recovery. Leakage from 
the jejunum is less dangerous than 
from the ileum, where bacteria are 
present in greater numbers. F. K. 
Boland (Jour. Med. Assoc, of Ga., vii, 
74, 1917). 


116 


ABDOMINAL INJURIES (LAPLACE). 


Such a diagnosis is further strength¬ 
ened by hematemesis or bloody stools, 
the former tending to indicate a 
lesion of the stomach. Death occurs 
in 96 per cent, of such cases if un¬ 
operated. 

In the differential diagnosis of ab¬ 
dominal contusion the greatest feat¬ 
ure for an early recognition of the 
existing conditions is whether there 
is unilateral or general tension of the 
abdominal wall, unless there is con¬ 
siderable blood-suffusion at the in¬ 
jured place. Aside from the reflex 
tension of the abdominal muscles, a 
slight, but distinct exacerbation of 
the general condition during the first 
few hours following the injury is a 
point of importance. With very care¬ 
ful observation, three or four hours 
may be allowed to elapse, but even 
then there is the possibility of error. 
Koerte reported a case where he was 
absolutely certain of his diagnosis 
and had decided to operate; the pa¬ 
tient, however, refused operation and 
made a smooth recovery. 

In the most favorable cases, where 
is but a slight tear, the mucous mem¬ 
brane will prolapse and occlude the 
aperture. Neighboring loops or the 
omentum will form a layer over the 
lesion with agglutination or adhesion, 
so that recovery may take place. If 
there is exudation of intestinal con¬ 
tents, a circumscribed, encysted ab¬ 
scess may form which is capable of 
resorption, or secondary perforation 
into the intestine or outward may 
occur; but it is equally possible that 
pus will find the dangerous route into 
the free abdominal cavity. 

In the most unfavorable cases, there 
is neither occlusion nor abscess for¬ 
mation; the inflammation will rapidly 
spread over large areas or over 
the entire peritoneum and cannot be 
checked. As early as four hours, ex¬ 
udate may be found; likewise, fibrin¬ 
ous deposits on the various loops. 
The more or less fulminating course 
is not only dependent upon the quan¬ 
tity of the exudate, but also on its 
infectious nature. 


Statistics show the rarity of cases 
in which the most favorable course, 
as depicted above, takes, place. Of 
160 cases of subcutaneous intestinal 
rupture in which the expectant treat¬ 
ment was instituted, 149 died; of the 
11 which recovered, 10 had to be 
operated during treatment for fecal 
abscesses and fistulje. Enderlen 
(Post-Graduate, July, 1911). 

For the detection of intraperitoneal 
rupture of the intestine from con¬ 
tusion, the abdomen should be care¬ 
fully examined every hour for pain, 
intensification of existing pain, and 
local tenderness. When the indica¬ 
tions point to rupture, expectancy 
should be limited to 1 hour. The 
writer sutures the rupture or resects 
the intestine and then mops up the 
peritoneal cavity without washing it 
out. He has had 8 complete re¬ 
coveries and 3 deaths. Soederlund 
(Nordiskt med. Arkiv, li. No. 5, 1919). 

Reports of 30 cases of detachment 
of the mesentery in abdominal con¬ 
tusion have been found by the writer. 
In 8 of these the detachment was the 
only lesion. It usually occurs in the 
terminal part of the ileum, but in 4 
cases it was in the middle part, and 
in 3 in the first part. The symptoms 
may be those of internal hemorrhage- 
and acute anemia. Or there may be 
an acute peritoneal syndrome. In a 
third type there is a syndrome of 
simple parietal contusion. 

In the first 2 types the symptoms 
demand immediate laparotomy. In 
the third there is no symptom of 
internal hemorrhage or peritonitis and 
the surgeon will probably delay lapar¬ 
otomy. In the author’s case absence 
of symptoms continued for 36 hours. 
In such cases gangrene of the de¬ 
tached intestine is certain to develop 
unless a prompt operation is per¬ 
formed. The peritonitis becomes 
manifest only 24 to 40 hours after the 
injury. L. Sencert (Bull, et mem. Soc. 
de chir. de Paris, xlvii, 758, 1921). 

Lesions of the Stomach.—Blows 
seldom cause rupture of the stomach, 
the elasticity of the organ, even when 


ABDOMINAL INJURIES (LAPLACE). 


117 


containing liquid or semiliquid ma¬ 
terial, being such as to cause it to 
escape injury under sudden impact 
or great pressure. It is also pro¬ 
tected by the lower ribs, the liver, 
and the intestines. Nevertheless, this 
organ is occasionally involved in 
traumatism affecting other abdom¬ 
inal viscera. In the majority of cases 
the rent is found near the pyloric 
orifice; but the greater curvature may 
be the seat of the lesion, while the 
entire organ is occasionally torn from 
end to end. In the latter case, 
however, death ensues almost imme¬ 
diately in practically all cases. Pres¬ 
sure during lavage of the stomach 
may also cause laceration of the 
mucous membrane. 

In the case of incomplete tears 
there may be hematemesis and severe 
localized pain resembling that of gas¬ 
tric ulcer,—gnawing and burning in 
character. This is followed by local¬ 
ized inflammation with tendency to 
the formation of adhesions. Hemor¬ 
rhage between the coats of the stom¬ 
ach may also occur in incomplete 
tears, a cyst-like pocket being formed. 

Violent pressure upon the stomach 
may cause it to be crushed against 
the spinal column, and the mucous 
surface be lacerated by interpressure 
of the anterior and posterior walls of 
the organ. In such a case a marked 
lesion necessarily follows, giving rise 
to copious hematemesis. 

Rupture of the stomach implicates 
the peritoneal coat in the majority of 
cases, the elasticity of the peritoneal 
investment being less than that of 
the two internal coats: muscular and 
mucous. The contents of the stom¬ 
ach, or a portion of them, escape 
into the peritoneal cavity and cause 
severe suffering and shock, followed 


promptly by death or septic peritoni¬ 
tis. Bryant teaches that a ruptured 
intestine is probably present, though 
this is not certain, when, after a 
diffuse injury to the abdomen or a 
severe local injury as the immediate 
result of the accident, there is little 
collapse, and when vomiting soon be¬ 
comes a prominent and persistent 
symptom, with lasting local pain and 
great thirst, with or without abdom¬ 
inal enlargement. 

According to Gluzinski, two signs 
which enable the physician to diag¬ 
nose the occurrence of intestinal per¬ 
foration before peritonitis has had 
time to manifest itself: 1, distinct¬ 
ness of the murmurs of the heart and 
respiration during auscultation of the 
abdomen, due to the presence of in¬ 
testinal gases in the peritoneal cavity. 
2, change in the pulse, which, at the 
moment of perforation, becomes accel¬ 
erated, to slacken some hours later, 
owing to the absorption of putrid 
gases acting as cardiac poison. 

In every case of perforation of the 
stomach or duodenum, free gas and 
fluid are present in the peritoneal 
cavity. The gas may pass between 
the liver and diaphragm, as shown by 
the X-ray, and cause obliteration of 
liver dullness. Much dependence can¬ 
not be placed on liver percussion as 
ordinarily practised, because of the 
very great variations, both in health 
and disease. Change of the patient’s 
position, however, will cause the fluid 
to flow to the dependent part, and the 
air to rise to the top, thus intensify¬ 
ing the findings. There is tympany 
over a wide liver area and again flat¬ 
ness over the same area on change 
of position. Normally there is also 
a change in the liver percussion note 
on change of posture, and normal 
liver changes must be recognized be¬ 
fore positive deductions are made. A 
fair comparison is the difference de¬ 
tected in shifting flank dullness in 


118 


ABDOMINAL INJURIES (LAPLACE). 


moderate ascites and in the normal 
abdomen. M. T. Field (Boston Med. 
and Surg. Jour., Feb. 14, 1918). 

Lesions of the Liver. —The liver, 
owing to its friable nature, its size, 
and its anatomical position, is the 
organ most frequently injured, be¬ 
cause indirect concussion may cause 
a profound lesion. A fall from a 
great height into water ,may thus 
cause a gaping rent of the capsule 
and parenchyma and open a large 
number of vessels. Severe and sud¬ 
den blows of any kind, especially 
those involving much surface, over 
the abdominal wall may thus cause 
injury to this organ. Again, its soft¬ 
ness, which may be increased by 
hypertrophy, causes it to yield readily 
to the crushing produced by carriage- 
wheels, car-bumpers, etc. 

Rupture of the liver according to Battle, 
is an extremely fatal accident, and the 
symptoms which ensue are usually marked 
and serious. Shock is present, frequently 
passing into collapse and death. Short of 
this there are vomiting, rapid pulse and 
respiration, pallor, etc. In this accident 
rigidity of the abdominal wall is very evi¬ 
dent, so that it may appear boardlike. 
Tenderness becomes localized to the 
hepatic region, and there is shifting dull¬ 
ness in the flanks with the ordinary symp¬ 
toms of loss of blood, according to the 
amount of it which is effused; the man 
becoming restless with a rapid, weak 
pulse, sighing respiration, and what is 
called “air hunger.” Jaundice may be a 
late symptom and is therefore of no use 
in the early diagnosis which is so very 
important. 

The severity of all the general 
symptoms is usually increased. The 
pain, when the liver is seriously in¬ 
jured, is peculiar; it radiates from the 
right hypochondrium to the waist, 
the scrobiculus cordis, or the scapular 
region. The respiration is generally 
embarrassed; there is marked shock. 


Examination of the feces may show 
the absence of bile, especially if the 
bile-duct is ruptured: an occasional 
complication. The dissemination of 
bile in the system causes itching and, 
after a time, jaundice. The escape 
of bile into the peritoneal cavity may 
not give rise to peritonitis, however, 
this fluid being aseptic. A serous 
exudate may result from the irrita¬ 
tion caused by its presence, forming 
a composite fluid which may be re¬ 
tained in the peritoneal cavity a con¬ 
siderable time. 

The most reliable symptom is the 
defense musculaire emphasized by 
Hartmann and Trendelenburg. Rig¬ 
idity is not the proper term for this 
condition, for rigidity rather denotes 
a tetanic state of the abdominal mus¬ 
cles, whether stimulated by pressure 
of the hand or not. It is not marked, 
except in the gravest cases, shortly 
after injury, but develops in the fol¬ 
lowing few hours from irritation of 
the peritoneum by the hemorrhage of 
intestinal contents from rupture of 
the intestines. It was especially 
mentioned twenty-four times in the 
44 cases, and in the remainder other 
signs, notably those of internal 
hemorrhage, were so marked that it 
was not noted in the history. Never¬ 
theless, it is not an infallible symp¬ 
tom, as proved by 2 cases related by 
Baum. Riebel (Quarterly Bull. N. 
W. Univ. Med. School, Sept., 1910). 

In reporting 3 cases of laceration 
of the right coronary ligament of the 
liver due to blows in the costal area 
on the right side, the writer gives the 
following diagnostic differential signs: 

From a renal injury, by the absence 
of costovertebral tenderness, absence 
of blood in the urine; the pain is 
located by the patient more anter¬ 
iorly in the flank and higher up than 
in renal injury. There are also signs 
of intraperitoneal irritation. 

From a rupture of the liver bulk it 
differs only in degree; the symptoms 
are more active, collapse is added to 


ABDOMINAL INJURIES (LAPLACE). 


119 


the shock, the abdomen is held more 
rigid, breathing is entirely costal, and 
the pulse continues to fail. M. R. 
Bookman (Med. Rec., Jan. 13, 1917). 

Umbilical ecchymosis is regarded 
as a symptom of wounds of the liver 
by the writer. His case was one of 
thoraco-abdominal injury, associated 
with wounds of the lung and the 
convex surface of the liver, in which 
ecchymosis in the upper half of the 
umbilicus appeared. Bonnet (Lyon 
Chir., Sept.-Oct, 1919). 

A rent is probable after a severe 
injury if there is collapse, if the pulse 
becomes more rapid and small, if the 
patient shows signs of exsanguinity, 
if the area of liver-dullness on per¬ 
cussion is increased, and if pain 
radiating to the scapular region is 
complained of. Severe injury may 
exist, however, without these indica¬ 
tions. 

Lesions of the Gall-bladder or 
Biliary Ducts.—Blows and other con¬ 
ditions capable of causing hepatic 
rents sometimes implicate these 
organs in the lesion. There may be 
severe pain in the right hypochon- 
drium if a rupture exists, vomiting 
of food and bile, and icterus. The 
urine is usually dark-mahogany and 
the stools ash-gray in color. Tender¬ 
ness over the hepatic region is usually 
marked. The intensity of the symp¬ 
toms depend to a degree upon the 
quantity of bile voided into the 
abdominal cavity; but, this secretion 
being aseptic, peritonitis only occurs 
as a complication when the perito¬ 
neum is itself implicated in the trau¬ 
matism, or when the lesion is at the 
junction of the biliary tract and the 
intestinal canal, the latter in that case 
acting as a source of infection. 

In the diagnosis of injury of the 
liver bradycardia is a suggestive sign. 
In one case the liver had been rup¬ 


tured by the kick of a horse and the 
pulse was only 48. In the other case 
the liver had been sutured and the 
pulse was 52. Several writers have 
mentioned bradycardia with injury 
of the liver, and ascribe diagnostic 
importance to it. The writer experi¬ 
mented on animals to determine the 
influence on the pulse of injury of 
liver and spleen. The results with 20 
animals showed that bradycardia is a 
characteristic symptom of injury of 
the liver, but that its absence does 
not exclude injury of this organ. 
Finsterer (Archiv f. klin. Chir., Bd. 
xcv, Nu. 2, 1911). 

According to Tilton hepatic injuries 
usually cause pain to radiate to the right 
shoulder. Inasmuch as there is also local 
pain on respiration, the chest does move 
as much on the right as on the left. This 
may lead to a misconstruction of the diag¬ 
nosis, for it suggests to the casual ob¬ 
server thoracic injury. The blood gravi¬ 
tates into the right iliac fossa and may 
give well-marked dullness. Disappearance 
of liver dullness is due to beginning tym¬ 
panites and is therefore not of great diag¬ 
nostic importance. Jaundice is occasion¬ 
ally present, but usually does not appear 
until the second or fourth day. Ludwig 
found it 24 times in 267 cases. Its pres¬ 
ence usually signifies injuries of the bile- 
duct. 

Lesions of the Spleen.—The causes 
of injury to this organ are the same 
as those of the liver. Rents, san¬ 
guineous infiltration, and partial 
crushing are the lesions most fre¬ 
quently observed. Enlargement of 
spleen through a malarial cachexia 
renders it susceptible to lesions 
which traumatism would not give 
rise to were it in its normal state. 

The malarial spleen seems particu¬ 
larly susceptible to rupture. The 
presence of a slow and strong pulse, 
after the phase of shock has passed 
off, does not exclude the possibility 
of a ruptured liver, since it is due to 
absorption of the biliary acids. Ab¬ 
dominal rigidity, the presence of an 


120 


ABDOMINAL INJURIES (LAPLACE). 


intra-abdominal fluid collection, local¬ 
ized or radiating pain, are the main 
symptoms. H. Finsterer (Wiener 
med. Woch., July 6, 1918). 

In extensive lesions copious hemor¬ 
rhage usually takes place and death 
rapidly follows. If the lesion present 
is less severe, however, and the hemor¬ 
rhage be moderate, there is tendency 
to collapse, increasing pallor, and a 
feeling of suffocation. The latter 
symptom and severe radiating pain 
in the region of the spleen are gener¬ 
ally present, besides the signs pecul¬ 
iar to all abdominal injuries. If the 
patient survives sufficiently long the 
immediate effects of the traumatism, 
peritonitis or abscess and other com¬ 
plications frequently result. Severe 
local pain generally continues for 
some time, and chills are not infre¬ 
quent. Percussion shows the organ 
to be more or less enlarged. 

According to Trendelenburg, vomit¬ 
ing is a most important guide in the 
diagnosis of rupture of the spleen; in 
simple contusion of the alimentary 
tract it is very seldom if ever 
encountered. 

The symptoms of traumatic rupture 
of the spleen are essentially those of 
internal hemorrhage, and the diagno¬ 
sis is usually not made until after ab¬ 
dominal section. The symptoms are 
obscure so far as enabling the distinc¬ 
tion whether the spleen or some 
other abdominal viscus is ruptured. 
However, there should be no difflculty 
in ■ diagnosticating the existence of 
hemorrhage into the abdominal cav¬ 
ity, and, when this condition is recog¬ 
nized, abdominal section is indicated. 
The incision should be made over the 
region of greatest dullness, if this can 
be determined. If percussion elicits 
a note of higher pitch in one flank 
than in the other, a valuable hint as 
to the source of hemorrhage has been 
obtained. Should the hemorrhage be 
sufficiently severe to give a percus¬ 


sion note of equal dullness in all 
regions the indication is to make the 
incision in the middle line. The treat¬ 
ment is essentially surgical, the ob¬ 
ject being the control of hemorrhage, 
and all authorities are agreed that 
this end is most certainly accom¬ 
plished by splenectomy. The mortal¬ 
ity following removal of the healthy 
spleen for rupture is al)out 40 per 
cent., whereas that of non-operative 
treatment is probably 100 per cent. 
Watkins (Med. Rec., Mar. 14, 1908). 

Case of a man who fell over an ob¬ 
struction, got up and walked a few 
steps, but was then seized with pains 
in the left thoracic base region. On 
examination his pulse was only 
slightly weakened. Beneath the left 
costal border there was some degree, 
of muscular resistance. The pains con¬ 
tinued and became more violent. 
Later his appearance grew worse and 
the abdomen became rigid, A diag¬ 
nosis of intraperitoneal hemorrhage 
probably due to rupture of the spleen 
was made, and the patient operated 
upon. The abdomen was full of 
blood and the spleen separated into 
2 distinct parts by a rupture perpen¬ 
dicular to its major axis. The pedicle 
was ligatured and the splenic cavity 
cleaned out. The postoperative 
course was simple. Examination 
showed that the rupture was at the 
union of the anterior and middle 
thirds; the capsule was largely de¬ 
nuded for about 3 cm. The author 
believes the rupture occurred in two 
stages: First, a parenchymal rupture 
with intrasplenic hemorrhage and for¬ 
mation of a subcapsular hematoma; 
secondly, upon an effort, capsular 
rupture and peritoneal inundation. 
Lefevre (Presse Med., p. 617, 1917). 
Lesions of the Kidneys.—The 
kidney is firmly held in place by its 
attachments, while its consistence is 
such as to preclude elasticity. Hence, 
a blow or undue pressure may cause 
rupture. All the causes of injury 
that may take part in the production 
of lesions elsewhere may also induce 


ABDOMINAL INJURIES (LAPLACE). 


121 


renal lesions, which may consist of 
contusion, rupture, or laceration. 

The 2 salient symptoms in con¬ 
tused wounds of the kidney in war 
are hematuria and perirenal hemat¬ 
oma. The first is observed in 95 per 
cent, of the cases. Unless primary 
hematuria is abundant, expectant 
treatment may be observed. 

Hematoma is of equal value with 
hematuria as a symptom. If it con¬ 
stantly increases, it indicates imme¬ 
diate operation which may otherwise 
be deferred. There is, however, dan¬ 
ger of the hematoma becoming in¬ 
fected if no operation is done, and 
there is a second danger of fibrous 
coating being formed around the kid¬ 
ney which may prevent its function¬ 
ing and giving rise to a chronic 
sclerous perinephritis. P. Nogues 
(Jour. d’Urol., vii, 123, 1918). 

The hidden gravity of such cases is 
well shown by the case of a girl, 4 
years old, who fell over backward 
while on a hobby horse, the saddle 
striking her directly across the ab¬ 
domen at the umbilical level. The 
only immediate effect was slight pain 
and tenderness over the right lower 
ribs. On the second day the tem¬ 
perature rose to 103.5® F. (39.7° C.). 
The tentative diagnosis was either 
injury of an abnormally placed ap¬ 
pendix or a hematoma of the ab¬ 
dominal wall. Although the acute 
symptoms then subsided, a mass ap¬ 
peared 1 week later below the free 
border of the ribs on the right side. 
This mass was very tender and pain¬ 
ful and was thought to be the liver, 
either abscessed or containing a new- 
growth, or an encapsulated hema¬ 
toma. It rapidly increased in size, 
and there was cardiac and respira¬ 
tory oppression with progressive 
anemia. On the 36th day an explora¬ 
tory laparotomy was done. The liver 
was found to be normal but entirely 
displaced by a large mass, which 
when opened was found to contain 
serum, blood and clots, and a few 
soft pale-gray masses resembling sar¬ 
comatous tissue of the small round- 


celled type. This mass proved to be 
the right kidney entirely disorganized 
and broken down, the tumor wall 
being the kidney capsule. The kid¬ 
ney was drained and packed. 

Autopsy revealed a slight loss of 
cortical substance and contusion of 
the kidney capsule, allowing a slow 
but progressive hemorrhage to take 
place beneath and within the capsule. 
H. P. DeForest (Jour. Dis. of Chil¬ 
dren, XV, 273, 1918). 

Besides the symptoms common to 
severe abdominal traumatism there 
may be increased pain in the lumbar 
region with radiations in the direc¬ 
tion of the pubis and rigidity of the 
muscles. Dullness on percussion is 
sometimes elicited. Anuria may also 
occur, but this is not a characteristic 
sign. Hematuria is an important in¬ 
dication of renal laceration, however, 
although it may not present itself at 
once; it may be followed by the ap¬ 
pearance of pus. The catheter should 
be used in these. Retraction of the 
testicles is also said to occur (Rayer). 
The ureter is very rarely involved; 
when it is, the symptoms are not 
modified. Enlargement of the lumbar 
and hypochondriac regions is present 
in the majority of severe cases, but 
may supervene late in the history of 
the case. 

Thanks to the compensatory work 
of the uninjured kidney, the mortality 
of renal lesions is not so marked as 
when other abdominal organs are 
injured. 

Even severe wounds have been 
known to heal. If large renal vessels 
are torn, marked lividity occurs, the 
patient rapidly becoming exsanguine. 
Death may thus follow very soon. 
Involvement of the peritoneum in 
the injury is promptly followed by 
peritonitis, the signs of this affection 
appearing a few hours after the 


122 


ABDOMINAL INJURIES (LAPLACE). 


receipt of the injury. Sepsis is not 
an infrequent complication in un¬ 
operated cases. 

When a patient has sustained an 
abdominal injury, manifesting the 
usual symptoms of shock, a gradually 
increasing resistant swelling over the 
kidney region requires prompt surg¬ 
ical intervention. The operation 
should be performed within the first 
12 hours after injury. The surgeon 
can discriminate between mild cases 
which need no surgical interference 
and those that manifest injury to the 
deep-seated organs. C. W. Roberts 
(Jour. Med. Assoc. Ga., vii, 81, 1917), 
PROGNOSIS.—Death almost in¬ 
variably attended rupture of the in¬ 
testinal tract prior to the introduc¬ 
tion of exploratory abdominal sec¬ 
tion, and prompt resort to active 
surgical procedures, when necessary, 
is indicated. 

As to the liver, as late as 1864 
wounds of this organ were considered 
as practically hopeless in every in¬ 
stance. While a very small propor¬ 
tion of these cases recover without 
surgical interference, as is shown by 
the scars occasionally found in the 
hepatic parenchyma, the fact remains 
that an exploratory laparotomy, per¬ 
mitting the surgeon quickly to arrest 
the loss of blood in case of hemor¬ 
rhage and to rid the peritoneal cavity 
of accumulated extraneous fluids, has 
greatly reduced the mortality. The 
prognosis becomes much more un¬ 
favorable when peritonitis has set in, 
but a fatal issue may sometimes be 
averted, even in advanced cases of 
this complication, by surgical inter¬ 
vention. 

The same remarks apply to rupture 
of the gall-bladder. 

Slight contusions of spleen heal 
readily, but rents and tears of any 
importance are frequently followed 


by fatal hemorrhage. Abscesses oc¬ 
casionally complicate convalescence. 

The great majority of cases of 
rupture of the kidney that recover 
are those in which the initial lesion 
had been comparatively slight. In 
the graver cases, in which there is 
copious hemorrhage into the peri¬ 
nephric tissues or into the peritoneal 
cavity, of which the growing exsan¬ 
guinity of the patient is an indication, 
the prognosis depends upon the 
speed with which adequate surgical 
procedures are instituted. Occasion¬ 
ally, however, the blood is held in 
check by the renal capsule. 

The prognosis depends greatly, 
therefore, upon the patient’s ability 
to stand operative procedures suitable 
to establish a positive diagnosis and 
bring the lesion that may at any 
moment destroy life within the imme¬ 
diate reach of art’s highest powers. 
When serious injury is rendered prob¬ 
able by the nature of the accident, 
and the symptoms present also indi¬ 
cate a serious lesion, an exploratory 
incision, if the patient is not past 
relief, a careful examination of the 
organs involved, arrest of hemor¬ 
rhage, closure of the disrupted tis¬ 
sues, or cleansing of the abdominal 
cavity may save him even when his 
condition appears almost hopeless. 

, Again, the prognosis is influenced 
by the time elapsing between the 
accident and the institution of surgi¬ 
cal procedures. The sooner they are 
resorted to, all things considered, the 
greater the chances of success. 

No case can be considered as hope¬ 
less unless a subnormal temperature, 
cold and cyanosed extremities, and 
other signs indicate that the end is 
near. 

Even when performed late in the 


ABDOMINAL INJURIES (LAPLACE). 


history of the case, adequate operat¬ 
ive measures sometimes prove suc¬ 
cessful. 

The mortality in injuries of the kidney 
is, under the best surgical procedures, 
about 30 per cent., according to Crawford. 
Death in these cases, if not immediate, as 
the result of shock, or hemorrhage, or in¬ 
jury to other important organs, is due (1) 
to anuria, (2) to infection, or (3) to secon¬ 
dary hemorrhage. Anuria is probably due 
to a reflex contraction of vessels in the 
sound kidney owing to stimulation of the 
splanchnics and the vagus endings (Mas- 
ius). Secondary hemorrhage may not oc¬ 
cur for a week or ten days after injury 
and is then due to a disintegration of 
blood-clots, which are acted upon by the 
urine. Infection may be (a) local, with 
deep cellulitis and subsequent general in¬ 
volvement; (b) peritonitis, or (c) an as¬ 
cending involvement of the opposite kid¬ 
ney due to the breaking down of blood- 
clots in the bladder. 

The early recognition of a rupture 
of the bladder greatly influences the 
prognosis. About 60 per cent, of the 
most unpromising lesion, intraperi- 
toneal laceration, are saved by prompt 
surgical measures. The remaining 
40 per cent, are unsuccessful mainly 
on account of delay in resorting to 
abdominal section. A favorable re¬ 
sult has, nevertheless, followed lap¬ 
arotomy as much as fifty-four hours 
after the rupture. 

TREATMENT. — Shock. — Shock 
or collapse, though unreliable as a 
sign of severe injury to the abdom¬ 
inal viscera, is, nevertheless, an 
alarming condition, especially if the 
temperature is subnormal and the 
breath is shallow, and it should at 
once receive attention. The patient 
is placed in bed with the head low, 
and a free supply of pure air insured, 
supplemented with oxygen if prac¬ 
ticable. Hot-water bottles are placed 
around him and he is covered with 


123 

blankets previously warmed, if pos¬ 
sible, or wrung out of hot water. 

Two main elements have to be 
borne in mind in this class of cases: 
(1) that the state of shock is due to 
a direct commotion of the sympa¬ 
thetic system with probable inhibition 
of the heart’s action, and (2) the pos¬ 
sibility of an internal lesion which 
may involve death by exsanguination 
or the outpour into the peritoneal 
cavity of gastric or intestinal fluids. 
While the first condition calls for 
stimulants adapted to sustain the flag¬ 
ging heart and restore the action of 
the vasomotors, the agents employed 
should not be administered by the 
mouth, since, in case of rupture of 
the stomach, the duodenum, or jeju¬ 
num, a portion, at least, of the fluid 
may be added to those that may have 
found their way into the peritoneal 
cavity. Rectal and subcutaneous in¬ 
jections should be resorted to. 

If no remedy be at hand, subcuta¬ 
neous injections of 1 dram of whisky 
or brandy may be employed, and re¬ 
peated every five or six minutes until 
reaction occurs. A turpentine stupe 
or a fresh mustard poultice (not 
plaster) over the xiphoid cartilage, 
and a rectal injection composed of a 
tablespoonful of turpentine, a raw 
egg, and a teacupful of warm water, 
sometimes act with surprising rapid¬ 
ity. Hypodermic injections of ether, 
or, better still, tincture of digitalis 
with ^20 gi'ain of atropine, repeated 
in fifteen minutes, are necessary to 
sustain cardiac action. After the 
second dose the digitalis may be in¬ 
jected alone several times more. 
These measures are greatly assisted 
by galvanic stimulation of the phrenic 
nerve, the negative pole, moistened in 
a solution of chloride of ammonium. 


124 


ABDOMINAL INJURIES (LAPLACE). 


being applied to the neck in the de¬ 
pression immediately in front of the 
sternomastoid muscle, and the posi¬ 
tive over the epigastrium. 

These means are sometimes ineffi¬ 
cient and hypodermoclysis should be 
performed. If a fatal issue seems 
inevitable, saline transfusion is indi¬ 
cated. 

Cases of abdominal wounds in more 
or less marked shock should receive 
at once a subcutaneous injection of 

1 or 2 eg. 0^ to Ys grain) of mor¬ 
phine, and then means be applied to 
increase the blood-pressure and vital¬ 
ity. Camphorated oil is given after 
the morphine in doses varying from 
3 to 4 c.c. (48 to 64 minims), at most 

2 c.c. (32 minims) being injected at 
the same point. Adrenalin is likewise 
given subcutaneously in doses of 1 
or 2 c.c. (16 to 32 minims) of a 
1:1000 solution. The saline may be 
administered hypodermically or intra¬ 
venously. If the shock is very severe, 
the patient should rest for not over 
two hours, the stimulant being re¬ 
peated at intervals. During the opera¬ 
tion it is necessary to combat shock 
by repeating injections at intervals. 
Postoperatively the Fowler position 
is not indicated in all cases; some 
may require a lateral decubitus or 
even a horizontal position with the 
head pendent, especially when there 
has been abundant hemorrhage and 
threatening anemia. Food and all 
drink is forbidden for the first twelve 
hours. Then only a spoonful of milk 
and water, brandy, or wine with 
water is given every hour. To over¬ 
come meteorism enemas of equal 
parts of warm water and glycerine are 
personally administered by the phy¬ 
sician. After expulsion of gas, the 
intestine is cleansed with warm salt 
water. W. Stoppato (Poficlin., xxiv, 
sez. chir., 1917). 

With reference to abdominal 
wounds in civil life, stress is laid on 
the increasing frequency with which 
preventable fatalities are observed 
from injury to intra-abdominal vis¬ 


cera accompanying external trauma 
without production of positively in¬ 
dicative local or general symptoms. 
It is the imperative duty of the sur¬ 
geon to intervene provided there ex¬ 
ists even presumptive evidence of in¬ 
ternal damage. A properly executed 
celiotomy is practically devoid of 
clinical risk. Where visceral damage 
has occurred the mortality under ex¬ 
pectant treatment is nearly 100 per 
cent. F. T. Fort (Internat. Jour, of 
Surg., Sept, 1920). 

Report of a case of accidental 
shooting in which the bullet punc¬ 
tured the bowel 7 times and passed 
out of the abdomen at the side oppo¬ 
site of entrance. No attempt was 
made to evacuate the intestine. An 
incision was started at the point of 
entrance of the bullet and extended 
along its course for 7 inches. Each 
small hole in the intestine was re¬ 
paired by inverting the ragged edges 
into the wound and closing with a 
double row of Lembert sutures, pene¬ 
tration of the mucous coat being 
avoided. A small drain of iodoform 
gauze was left in the wound until the 
bowels had moved twice. Prompt 
recovery followed. Vertner Kener- 
son (N. Y. Med. Jour., Sept. 7, 1921). 

Report of a case in which an opera¬ 
tion was performed 2 hours after a 
pistol wound of the right hypochon- 
drium. A tunnel wound of the liver 
was found, and was controlled by 
gauze packing. The gauze was re¬ 
moved on the fourth day and recovery 
followed. Another case, in a girl of 
12 years, was operated upon 6 hours 
after the infliction of wounds. Five 
perforations were found in the small 
intestine. These were sutured. A 
cigarette drain was left in the cavity, 
and removed in 2 days. Recovery 
took place. Charles Farmer (Ky. 
Med. Jour., Sept. 1921). 

Reaction.—As soon as reaction oc¬ 
curs in these cases another danger 
threatens the patient, that of hemor¬ 
rhage, which the state of collapse has 
so far prevented to a degree, unless 
an extensive injury has caused over- 


ABDOMINAL INJURIES (LAPLACE). 


125 


whelming exsanguination. In this 
event, however, the patient’s recovery 
from the preliminary shock would 
hardly have taken place. Hence the 
necessity of closely watching the 
sufferer. 

Cases of prolonged collapse some¬ 
times turn out to be trivial, while a 
short period of it may be the prelude 
to the most grave complications. 
The former cases are, unfortunately, 
rare, and profound shock of any dura¬ 
tion should be looked upon with sus¬ 
picion. This is especially the case 
when a second period of shock is 
passed through—the “relapsing col¬ 
lapse” of Bryant—indicative of a 
secondary hemorrhage or the giving 
way or separation of some damaged 
tissues. 

The condition after subcutaneous 
rupture of the abdominal wall may 
become very serious in a short time. 
Any surgical procedure instituted 
must be thorough, all intestinal le¬ 
sions being repaired, bleeding points 
checked, and blood-clots, when 
abundant, all removed. For the peri¬ 
tonitis arising from fecal material in 
the abdominal cavity good drainage 
with tubes must be established, with 
saline proctoclysis and hypodermo- 
clysis, enterostomy and saline flush¬ 
ing of the bowel for intestinal pare¬ 
sis, and repeated stomach washing 
for vomiting and gastric distention. 
Dardanelli (Rif. med., June 8, 1912). 

That cases clearly showing by 
their history and the active symptoms 
a grave injury should be submitted 
to surgical measures as early as pos¬ 
sible will hardly be gainsaid in the 
light of our present knowledge. An 
equally positive conclusion, based on 
every means of diagnosis available, 
will alone warrant the assertion that 
no serious injury is present; but, if 
on the other hand, doubt exists. 


abdominal section will alone insure 
the patient adequate protection. If 
nothing be found, no harm will have 
been done if precepts governing asep¬ 
tic surgery have been closely fol¬ 
lowed ; if a rent in the liver, an 
intestinal tear or rupture, a serious 
hemorrhage be discovered and ade¬ 
quately dealt with, the patient will 
have received the benefit of all our 
art’s resources. 

The seat of rupture being located, 
the nature of the injury will deter¬ 
mine the procedure to follow, linear 
enterorrhaphy being indicated in 
longitudinal ruptures, and circular 
enterorrhaphy in complete ruptures. 
These procedures are now generally 
preferred to an artificial anus. It is 
sometimes impossible to adjust ade¬ 
quately the edges of the wound, 
owing to the condition of the margin, 
and an omental graft must be used 
to cover the contused area so as to 
avoid a secondary perforation. 

Considerable extravasation of feces, 
blood, and other liquid or semiliquid 
material may have occurred into the 
peritoneal cavity. All chances for 
further contamination of the intes¬ 
tinal tract having thus been removed 
by closure of the rupture, the peri¬ 
toneal cavity should be carefully 
cleansed by flushing with warm, steri¬ 
lized water, a soft aseptic sponge 
being employed to mop gently all the 
surfaces that may, in any way, have 
come in contact with the infectious 
fluids. The cavity is then closed and 
free drainage insured. 

Satisfactory results are obtained 
even in cases in which very great in¬ 
jury and ample opportunity for infec¬ 
tion of all wounds have markedly 
compromised the issue. 

The after-treatment should be 


126 


ABDOMINAL INJURIES (LAPLACE). 


based upon the necessity of insuring 
rest for the intestinal tract for a few 
days. This may be carried out by 
administering opiates. The patient’s 
strength should be sustained by 
means of nutrient, but small and fre¬ 
quently administered, enemata. 

Under all circumstances, an abdom¬ 
inal injury should cause the patient 
to be watched several days. After an 
uncomplicated injury he should re¬ 
main in bed and be placed on a milk 
diet for a few days. Anodyne appli¬ 
cations over the abdomen and a little 
morphine, internally, if there is pain, 
is all that is usually required in these 
cases. In the less fortunate the pro¬ 
cedure to be adapted varies according 
to the organ involved. 

Intestines.—The probability of a 
rupture having been recognized, the 
abdomen should be opened by an in¬ 
cision through the linea alba, and any 
hemorrhage quickly arrested. 

The next step is to locate the 
visceral injury. Of importance in this 
connection is the fact that in the 
majority of cases the rupture is due 
to compression against the spinal 
column. The spot over the abdo¬ 
men upon which the blow carried 
being considered as the one end of 
an imaginary line and the center of 
the vertebral column as the other 
end, the probabilities are that the 
rupture will be found near the linear 
axis. 

Again, if the rupture cannot be 
readily found, hydrogen may be 
gently insufflated into the rectum, as 
advised by Senn, and the spot from 
which the gas escapes will indicate 
the location of the rupture,—approxi¬ 
mately, in the case of the small intes¬ 
tine, and accurately below the ileo¬ 
cecal valve. 


Disorders, or lesions other than 
those sought after, are misleading 
conditions that should be borne in 
mind. 

Lesions of the jejunum are some¬ 
times difficult to locate. 

Stomach.—When the symptoms of 
complete tear are recognized, the 
presence of the organ’s contents in 
the abdominal cavity render an imme¬ 
diate laparotomy imperative. The 
incision should include the tissues 
between the xiphoid cartilage and the 
umbilicus. If the tear cannot be 
quickly found, repetition of the infla¬ 
tion with hydrogen-gas will help to 
locate it. As soon as located any 
bleeding vessel should be ligated, and 
the stomach evacuated and cleansed 
through the adventitious opening of 
any substance that may have re¬ 
mained in it. If the wound be a 
lacerated one, it may be necessary to 
pare its edges. This being done, the 
tear is closed, the mucous membrane 
being united with a continuous or 
interrupted suture, cut short, and the 
muscular and serous coats by the 
continuous Lembert suture. Closure 
of the laceration having removed all 
danger of further extravasation into 
the peritoneal cavity, the latter must 
be flushed with warm, sterilized 
water and mopped out with a soft 
sponge. The cavity is then closed 
and a drain left if the peritoneal sur¬ 
faces have been exposed to contami¬ 
nation for some time. 

Liver.— Especially when the history 
of the case seems to indicate the pos¬ 
sibility of a lesion of this organ is 
careful watching imperatively de¬ 
manded, owing to the violent hemor¬ 
rhages which they involve. Either 
this complication or peritonitis having 
been recognized, the abdomen should 


1 



Lines of Incision for Abdominal Kxploration and Operation (Laplace). 

1, median line; 2, for liver and gall-bladder; 3, for pyloric end of stomach and 
duodenum; 4, 4', for upper abdomen, including stomach and pancreas; 5, for spleen; 6, 
for tail of pancreas or greater curvature of the stomach; 7, umbilicus, median line; 8, 
8', 9, 9', 10, 10', for intestines according to location of injury, 8 being the best for 
appendix as'it severs no muscular fibers; 11, vermiform appendix; 12, McBurney’s line; 
13, cecum and ileum; 14, anterior superior spinous process of the ileum; 15, 16, 17, 18, 
defective incisions for appendicitis: they cut across deep muscular fibers; 19, 19', for 
inguinal hernia; 20, 20', 21, 21', for bladder according to location of injury. 










































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ABDOMINAL INJURIES (LAPLACE). 


127 


be opened at once in the middle line. 
The abdominal wound should be 
large enough, if possible, for the 
surgeon to see the liver, but in every 
case he ought to make a careful ex¬ 
ploration with his finger, especially 
directing his attention to the convex 
and posterior surfaces of the organ. 

When a rupture is found, the 
wound may either be cauterized, 
plugged, or sutured. 

Plugging with antiseptic or aseptic 
gauze seems to give the best results, 
one end of the gauze being left out 
at the angle of the abdominal wound. 
The plug should be removed not 
earlier than the forty-eighth hour, 
lest there should be a recurrence of 
the hemorrhage, and not later than 
the fourth day, lest a biliary fistula 
should be formed. When the bleed¬ 
ing is very severe, sponges mounted 
on holders appear to produce more 
satisfactory pressure than simple 
plugging, which is, perhaps, better 
reserved for slighter injuries. Hot- 
water irrigation may be of advantage 
in these cases. A ligature should be 
applied to any large vessel which is 
seen to have been torn. Sutures are 
particularly useful when the lacera¬ 
tion extends deeply into the substance 
of the liver, since by their means the 
edges of the wound may be brought 
lightly together and the bleeding can 
be controlled. Drainage of the pelvic 
pouch, by an opening just above the 
pubis, serves best to give free pas¬ 
sage to subsequent discharges. The 
capsule should be included in the 
stitches. The prognosis is very un¬ 
favorable when peritonitis has oc¬ 
curred, but something may still be 
done to prevent the fatal issue by 
opening and afterward draining the 
abdominal cavity. 


in suturing the liver, the writer 
passes the needle, threaded with cat¬ 
gut, through a small wheel made ot 
fine silver wire. Each wheel, the 
diameter of which varies from 6 to 
15 mm., has 8 spokes. A. L. Soresi 
(Riforma Medica, Mar. 2, 1917). 

In a case of traumatic rupture of 
the liver in a boy, aged 8 years, due 
to being run over by an automobile, 
the outstanding signs were the thor¬ 
acic type of breathing, the anxious 
expression, and the history of severe 
trauma. Normal urine was voided. 
When there is a possibility of a solid 
abdominal viscus being damaged, it 
is generally safer to explore at once 
rather than await the symptoms of 
hemorrhage. Doyle (Med. Jour, ot 
Australia, Jan. 10, 1920). 

Spleen.—After a simple contusion 
the spleen soon returns to its normal 
condition without further trouble, 
and a few days in bed, coupled with 
strapping of the side to limit motion, 
usually suffice. When,' however, 
there is laceration of the parenchyma 
the convalescence is slow, abscesses 
following in quick succession. After 
a time these cease and recovery is un¬ 
interrupted. Symptomatic treatment, 
revulsion over the organ, and tonics 
may shorten the duration of such 
cases. 

When the symptoms do indicate 
that exsanguination of the patient is 
taking place, death will most prob¬ 
ably follow, although the hemorrhage 
is not as copious as it can be in tears 
of the liver, the splenic capsule being 
more elastic than that of the latter 
organ. Removal of the organ should 
be resorted to. The abdominal wall 
is opened by means of an incision 
through the left semilunar line and 
the peritoneum is freely opened. The 
hand being introduced into the cavity, 
all adhesions are torn up and the 
organ is brought to view. The 


128 


ABDOMINAL INJURIES (LAPLACE). 


vessels entering the hilum are then 
clamped and the organ is removed. 
The stump is ligated and, after spong¬ 
ing out the abdominal cavity, the 
wound is closed. 

Summary of cases of rupture of the 
spleen reported in literature: Unop¬ 
erated: Of 220 cases, 17 patients re¬ 
covered—mortality, 92.3 per cent. 
Operative results: Splenectomy, 67 
cases, 38 patients recovered, 29 died 
—mortality, 56.7 per cent.; splenor- 
raphy, 2 cases, 1 patient recovered, 
1 died—mortality, 50 per cent; tam¬ 
ponade, 6 cases, 5 patients recovered, 
1 died—mortality, 83.3 per cent. In 
the splenectomies, 13 patients had 
complicating injuries, of which 9 
died. In 2 which recovered, the 
complications were unimportant. Ross 
(Annals of Surg., July, 1908). 

Kidney.—The majority of mild 
cases of perirenal extravasations of 
blood and urine recover as the result 
of rest and expectant treatment. The 
patient should be kept in bed and his 
diet limited to liquids, the best of 
which is milk; this beverage requires, 
besides, the least physiological labor 
from the injured organ. The nourish¬ 
ment of the patient may further be 
sustained by rectal injections of beef- 
tea, and these should entirely be 
resorted to if there is vomiting, the 
latter tending greatly to encourage 
hemorrhage. 

Details of 5 cases. The patients 
were men between 25 and 42, a 
woman of 30, and a boy of 12. Un¬ 
less there are signs of internal hemor¬ 
rhage, absolute repose and ice to the 
kidney region are indicated. The pa¬ 
tients were all dismissed in good con¬ 
dition after operative intervention. 
Yoshikawa (Beitrage z. klin. Chir., 
Jan., 1909). 

When hemorrhage occurs in the 
direction of the bladder, there is 
likely to be accumulation of blood- 
clots, which, if small, will readily 


pass out with the urine. Frequently, 
however, the clots are large and cause 
retention of urine and marked tenes¬ 
mus. A large catheter should there¬ 
fore be introduced and kept in situ 
when the hematuria is markedy and 
the bladder occasionally washed out 
with a weak boric acid solution. 
Median urethrotomy to remove clots 
and relieve retention sometimes be¬ 
comes necessary in these cases. 
When the symptoms do not improve 
under these measures, an incision 
should be made, exposing the seat of 
injury, the extravasation removed, 
and the parts restored to their normal 
conformation. 

According to Keen, hematuria is 
valuable only as showing the fact of 
rupture of the kidney, but not as a 
symptom by which to decide on 
operating. It is not the visible loss 
of blood by the bladder, but the 
easily overlooked, but far from 
dangerous, bleeding into the peri¬ 
nephric tissues, or into the peritoneal 
cavity, that should receive the chief 
attention. 

The dangers of rupture of the 
kidney are mainly hemorrhage and 
sepsis. When, therefore, the symp¬ 
toms are such as to indicate marked 
hemorrhage or sepsis, and especially 
if a tumor form quickly in the lum¬ 
bar region, an exploratory operation 
should at once be done. If severe 
laceration be present, or the kidney’s 
functions be practically compromised, 
or the hemorrhage be such as to 
require ligation of the renal vessels, 
lumbar nephrectomy should immedi¬ 
ately be performed, primary nephrec¬ 
tomy being safer than secondary rer, 
moval of the organ. 

When hematuria continues and a 
hematoma forms in the region of the 


ABDOMINAL INJURIES (LAPLACE). 


129 


kidney which seems to be increasing 
in size, and when there are symptoms 
of concealed hemorrhage, it is far 
better to operate then under good 
conditions than to wait until the risk 
is greatly increased. Even if the 
hematoma does not appear a hemor¬ 
rhage may be dissecting up tissues 
for a considerable distance, and then 
the evidence of concealed hemorrhage 
must take the place of evidence of a 
hematoma. The danger of an ex¬ 
ploratory operation is not great if it 
is undertaken before too extensive 
hemorrhage or septic infection has 
taken place. Frank Walker (Boston 
Med. Surg. Jour., May 24, 1917). 

Bladder.—When a patient presents 
the history of a severe abdominal 
contusion or crushing-, followed by 
inability to micturate, the catheter 
should at once be used. 

The presence of hematuria will 
indicate a lesion in the urinary tract, 
kidney, or bladder. If the urine with¬ 
drawn is observed to be well mixed 
with blood and, instead of red, it ap¬ 
pear brown and smoky, the lesion is 
probably one of the kidney. If, on 
the contrary, the urine be bright red, 
the probability is that the bladder has 
been torn. In the latter condition 
the diagnosis may also be assisted by 
the quantity of fluid passed at a given 
time. If, when the catheter is intro¬ 
duced and after a history marked 
with shock, no urine is obtained, the 
chances are that not only the bladder 
has been ruptured, but that the 
laceration is extensive, the opening 
having allowed the vesical fluids to 
escape into the abdominal cavity. A 
free flow, on the contrary, would tend 
to show that the tear, if any exist, is 
small. Of course, the invagination of 
the intestines into the vesical open¬ 
ing, or a valve-shaped laceration, may 
cause the same favorable signs to 
exist, thus misleading the diagnosti¬ 


cian. Very small lesions may be 
present, sufficient to allow the urine 
to escape, drop by drop, into the sur¬ 
rounding parts. Detection of them 
is very difficult, the subsequent com¬ 
plications alone showing the presence 
of extravasated fluids. 

The presence of any tear, except 
very small ones, may also be ascer¬ 
tained by injecting a weak boric acid 
solution into the organ, through the 
catheter. If a rupture be present, the 
bladder will not fill and rise above 
the pubis. Filtered air may be used 
for the same purpose, but it is less 
satisfactory, owing to the danger of 
secondary collapse. 

The urine may have passed into 
the prevesical connective tissue out¬ 
side the peritoneum, or the vesico¬ 
rectal or vesicouterine space, owing 
to a rupture in these locations. This 
constitutes the extraperitoneal lesion. 
Cellulitis and sloughing rapidly ensue 
without subsequent involvement of 
any organ in the neighborhood of the 
lesion, the vagina, the rectum, etc., 
the patient dying from septicemia. 

Death in intraperitoneal rupture of 
the bladder is due in a majority of 
cases to uremia and not to peritonitis. 
In most instances death occurs before 
the latter can develop. One should 
operate whenever there is suspicion 
of intraperitoneal rupture and not 
wait for evidences of a peritoneal re¬ 
action. Rost (Miinch. Med. Woch., 
Jan. 2, 1917). 

To ascertain whether a tear be 
extraperitoneal or not, a measured 
quantity of a weak boric acid solution 
is injected through the catheter. If 
the full amount is not recovered, the 
chances are that the rupture is extra¬ 
peritoneal. 

Report of a case of traumatic rup¬ 
ture of the bladder in which an un- 


130 


ABDOMINAL INJURIES (LAPLACE). 


usual feature was the obtaining of 
urine in considerable quantities after 
catheterizing the patient. The patient 
had been kicked on the lower abdo¬ 
men. The house surgeon passed a 
catheter and obtained about 10 ounces 
of blood-stained urine. Eight hours 
later 16 ounces of urine were drawn 
off. The bladder was washed out 
with boric solution, the solution re¬ 
turned being apparently the same in 
quantity as was injected. L. Gordon 
(So. Africa Med. Rec., Feb. 28, 1920). 

Rupture into the peritoneal cavity, 
the intraperitoneal form of lesion, is 
less urgent as far as symptoms go. 
One, and even two, days may elapse 
before active symptoms appear; but, 
when they do, rapid progress toward 
a fatal issue from general peritonitis 
is the rule. 

Uncomplicated contusion of the 
bladder readily yields to a few 
days’ rest, the application of ice, 
and general symptomatic treatment. 
When, however, there is cause for 
suspecting a rupture from the nature 
of the accident or the violence of the 
blow, the catheter should at once be 
introduced. The presence of blood 
renders operative interference im¬ 
perative. After the rectum has been 
distended with a rectal bag an inci¬ 
sion three inches long is made in the 
middle line of the hypogastrium, 
beginning half an inch below the 
upper edge of the pubes, as in supra¬ 
pubic lithotomy. 

The peritoneum is then carefully 
rolled up, along with the prevesical 
fat. The bladder being thus exposed, 
search for the rupture is the next 
step. The rent is usually found along 
the posterior surface vertically down 
from the urachus; frequently an 
extravasation of blood and urine 
indicates the spot. Occasionally, 
however, considerable difficulty is 


experienced, and opening of the organ 
is necessary so as to permit the in¬ 
troduction of the finger, and thus 
allow of exploration of its inner 
surface. 

The rupture may be extraperi- 
toneal or intraperitoneal. If an intra¬ 
peritoneal laceration is found, the 
incision should be extended upward, 
the peritoneal cavity opened, and the 
cystic wound closed with fine silk by 
means of Lembert sutures, one-eighth 
of an inch apart, including only the 
peritoneal and muscular coats. The 
mucous membrane of the bladder 
should be respected. Important, in 
this connection, is the necessity of 
ascertaining, that the sutures will 
hold; this may be done by distending 
the bladder with a lukewarm milk or 
an alkaline solution. 

The abdominal cavity is then care¬ 
fully irrigated and closed, leaving a 
drain if there is any possibility that 
fluids will accumulate in any of the 
surrounding tissues. 

Henry Morris holds that there is 
great danger in delaying operation in 
these cases; the decomposition of the 
clots and the cystitis which is excited 
by their presence, as well as the fre¬ 
quent catheterization needed, exposes 
the patient to all the dangers of sup¬ 
puration of the wounded kidney, and 
also to the risk of infection. 

Patients who recover from extra- 
peritoneal rupture are more apt to 
suffer permanent disability than those 
who recover from intraperitoneal rup¬ 
ture, chiefly because of the urinary 
extravasation about the base of the 
bladder, inducing infectidn, necrosis, 
and loss of function. 

The treatment consists in drainage 
of the bladder either infra- or supra- 
pubically. Suture of the bladder tear 
is of less importance in extraperito- 
neal cases. For an associated pelvic 


ABDOMINAL INJURIES (LAPLACE). 


131 


fracture open operation wiring, etc., 
are unsatisfactory because of urinary 
infiltration. Indirect fixation by ex¬ 
ternal screws and clamps was found 
useful in a boy of 16, injured in a run¬ 
away. A Freeman’s screw placed on 
either side of the symphysis pubis 
held the pubes in apposition until 
fibrous union was well established. 
The total mortality in all varieties of 
ruptured bladder treated surgically 
since 1900 has been less than 25 per 
cent. E. P. Quain (Surg. Gynec, and 
Obstet., xxiii, 55, 1916). 

Case of a man who had been kicked 
in the abdomen and jumped upon 
while intoxicated. The abdomen was 
rigid as in perforated duodenal ulcer; 
temperature, 102.5° F. (39.1° C.); 
pulse, 100 to 110. Three ounces of 
clear urine had been passed. Upon 
incising the peritoneum there was a 
gush of blood-stained fluid, possibly 
2 quarts. A tear in the bladder from 
the space of Retzius down to the tri¬ 
gone was found. The balance of the 
fluid was aspirated from the abdomen 
and the operation concluded by sutu¬ 
ring the rent in 3 layers, No. 1 
chromic catgut being used first in the 
mucosa, the second layer including 
the muscular and serous coats and 
last the serous. A drain was placed 
in the pelvis and a catheter intro¬ 
duced through the urethra and fixed 
with a suture through the corpus 
spongiosum. The patient was placed 
in bed in the Fowler position with a 
Murphy drip. He was out of bed 
and voiding 16 ounces at a time on 
the tenth day. Erdman (N. Y. Med. 
Jour., Oct. 13, 1917). 

Case of a man struck in the lower 
part of the abdomen by the pole of a 
wagon. The symptoms continued for 
nearly five days before he came to 
the hospital. Temperature, 100° F. 
(37.8°C.); pulse, 132; respiration, 32; 
white blood cells, 15,000; polynu- 
clears, 73 per cent. The abdomen was 
opened and 130 ounces of fluid ob¬ 
tained. A small transverse tear found 
in the upper portion of the bladder 
was sutured and the bladder drained 
below the peritoneum through a stab 


wound; the abdominal wound was 
also sutured and drained. Recovery 
was uneventful. E. F. Kilbane (N. 
Y. Med. Jour., Oct. 20, 1917). 

In retroperitoneal intestinal rupture 
from contusion operative treatment 
is especially difficult. In 37 cases of 
retroperitoneal rupture in the litera¬ 
ture, 29 cases were treated surgically, 
but in only 15 was the rupture dis¬ 
covered at operation. The surgeon 
may consider the condition due to 
retroperitoneal hemorrhage and close 
the abdomen with fatal results. Su¬ 
ture, though difficult, can be done 
with hope of success in selected cases. 
G. Soederlund (Nordiskt nied. Arkiv, 
li, No. 5, 1919). 

WOUNDS OF THE ABDOMEN. 

—Wounds of the abdomen may be 
non-penetrating, when the abdominal 
walls alone are injured, and penetrat¬ 
ing, when the peritoneum is included 
in the lesion, irrespective of the in¬ 
strument (pistol, knife, etc.) with 
which the lesion is produced. 

Non-penetrating Wounds. — Non¬ 
penetrating wounds are usually due 
to pointed cutting or blunt instru¬ 
ments. 

The lesions caused by a pointed in¬ 
strument, involving the skin and 
muscles only, are usually very slight. 
With due aseptic precautions careful 
exploration of the wound with the 
finger may be resorted to if the 
visual examination does not suffice. 
Probes had better not be used, lest 
the wound be transformed into a 
penetrating one. 

Lesions caused by cutting instru¬ 
ments (knives, swords, etc.) vary in 
importance according to their depth 
and length. When the muscles are 
cut, the support for the abdominal 
organs is compromised, and ventral 
hernia may follow, unless great care 
be taken when the wound is closed. 

Lesions caused by blunt bodies 


132 


ABDOMINAL INJURIES (LAPLACE). 


(such as shot, glancing bullets, and 
fragments of shells, etc.) are usually 
attended by symptoms of contusions 
corresponding in intensity with the 
force of the blow. Severe laceration 
of the abdominal tissues may thus be 
caused and death occur from intes¬ 
tinal lesions. 

The hemorrhage attending these 
various kinds of wounds is usually 
slight. There is considerable ecchy- 
mosis, but this soon disappears. Oc¬ 
casionally shots or bullets become 
imbedded in the abdominal tissues. 

The best sign of coexisting injury 
to one or more abdominal organs is 
rigidity, coupled, if there is abundant 
hemorrhage, with a small pulse, 
pallor, a pinched facies, and vomiting. 
Even slight abdominal trauma may 
entail severe symptoms, which, how¬ 
ever, gradually decrease in intensity, 
whereas if actual organic injury has 
been occasioned, their intensity con¬ 
tinues to increase. H. Riedel (Deut. 
med. Woch., Jan. 11, 1912). 

The writer lays stress on transmis¬ 
sion of the cardiac and respiratory 
sounds, so that they are audible over 
the whole abdomen almost as well as 
over the chest, as a sign of internal 
injury and positive indication for im¬ 
mediate laparotomy. This sign may 
already be present one-half hour after 
the injur}^ never exists in extraperi- 
toneal injuries, has no relation to 
rigidity, and is ascribed to irritation 
of the parietal peritoneum through 
the outpouring of foreign material 
into the abdominal cavity. Claybrook 
(Surg., Gynec., and Obstet., Jan., 
1914). 

Visceral extraperitoneal wounds 
showed symptoms more marked, 
lasting, and alarming than parietal 
injuries. The symptoms giving the 
impression of peritoneal penetration 
are: dullness over the liver, muscular 
rigidity of all or part of the anterior 
wall, vomiting, small pulse, facies ab- 
dominalis, stoppage of flatus and feces 
which persists more than twenty- 


four hours, retention of urine, and 
traumatic shock. Any one or more 
of these signs may show in an abdom¬ 
inal wall injury, but the occurrence of 
all together is rare. Before the war 
any of these symptoms would usually 
have been considered indicative of in- 
traperitoneal penetration. Tympa¬ 
nites was observed in 56 per cent, 
of the writers’ series of extraperito¬ 
neal wounds. Stassen and Voncken 
(“Le peritoine en chir. de guerre,” 
Paris, 1917). 

It is sometimes impossible without 
a laparotomy to tell whether a gun¬ 
shot wound of the abdomen involves 
the peritoneal cavity or not, for the 
signs and symptoms are not constant. 
It is first necessary to determine if 
possible the direction of the track. 
The absence of an exit wound does 
not necessarily mean that the foreign 
body is lodged in the abdomen. The 
facial expression is usually one of 
anxiety. Pain is not of great value, 
and may or may not be present. 
Tenderness is a very constant and 
reliable sign. Rigidity, or the ab¬ 
sence of it, is often most misleading. 
The pulse increases directly with the 
gravity of the intraperitoneal lesion, 
and gives an important basis for 
prognosis. Vomiting is usually pres¬ 
ent, but not necessarily. Thirst is a 
most distressing symptom. Roentgen- 
ray localization affords the most use¬ 
ful guide in the diagnosis of penetrat¬ 
ing wounds. Operation should not 
be undertaken before the patient has 
recovered from shock. In patients 
with shock and hemorrhage the au¬ 
thor has often waited six hours or 
more, taking the risk of further hem¬ 
orrhage, with results that justified 
the delay. Provided the patient is 
warm, operation is done at once, 
saline being given while he is on the 
table. Charles (Brit. Med. Jour., 
Mar. 23, 1918). 

Treatment.—After carefully arrest¬ 
ing bleeding, cleansing, and disin¬ 
fecting the wound, the tissues are 
united. In deep incised wounds the 
prevention of ventral hernia should 


ABDOMINAL INJURIES (LAPLACE). 


133 


be borne in mind, and the cut mus¬ 
cular tissues broug'ht accurately to¬ 
gether by means of catgut sutures. 
This being done, silk sutures are also 
introduced and brought out to the 
surface, thus including the muscles 
and skin. Capillary drains are alone 
to be used, if drainage is at all neces¬ 
sary, larger drains affording oppor¬ 
tunity for the formation of a ventral 
hernia. The abdomen should be sup¬ 
ported by means of a bandage applied 
over the dressing and the patient kept 
in bed until complete repair of the 
wound has taken place; from two to 
five weeks, as a rule. The bandage 
should be carried long after recovery, 
and the patient be warned of the 
danger he might incur by violent 
movement or strain. 

Penetrating Wounds.—The soft¬ 
ness of the tissues of the abdominal 
parietes causes them to be easily 
penetrated, and the organs within the 
cavity are all vulnerable for the same 
reason. The interstices between 
them occasionally allow the harmless 
passage of a weapon or bullet, but 
such cases are extremely rare. 

The missile may graze the perito¬ 
neum and barely miss it along with 
the deeper organs. Unfortunately 
wounds causing laceration of one or 
more of the abdominal viscera are the 
most frequent, and their fatality is 
proverbial unless a timely diagnosis 
allow of prompt protective measures. 

As is the case in contusions, the 
direction from which the missile or 
stab comes is of great importance. 
A bullet arriving from the side and 
striking near the linea alba 'would 
probably create a buttonhole wound 
or bury itself in the abdominal walls. 
A bullet coming from the front, on 
the contrary, would most probably 


perforate the organs in its axial line 
of flight. If the bullet has passed 
through the body an imaginary line 
between the entrance and exit will 
probably indicate the organs injured, 
including, of course, the peritoneum. 
Here again, however, the spinal 
column may cause deviation when 
the initial velocity of the bullet is 
small, and a deceptive line of injury 
furnished. To positively determine 
the course of a bullet is difficult in 
many cases. 

In stab wounds the opening is fre¬ 
quently of a sufficient size to permit 
prolapse of the omentum: an evident 
proof that the abdominal cavity has 
been penetrated. This rarely occurs 
in bullet wounds unless a large pro¬ 
jectile, or a bullet coming from either 
side of victim, has caused com¬ 
paratively large solution of continuity 
of the tissues. Prolapse of the omen¬ 
tum is most frequently observed in 
lesions of the left side. Coils of the 
small intestines are also frequently 
prolapsed and, in rare cases, the 
stomach, the liver, or the spleen has 
appeared between the lips of the 
wound. 

Symptoms.—As is the case after 
contusion, penetrating wounds of the 
abdomen may give rise to no symp¬ 
toms capable of affording any reliable 
clue to the extent of the internal in¬ 
juries. Profound shock may be pres¬ 
ent and no serious lesion exist. 

Severely injured individuals may, 
on the contrary, present no acute 
symptoms and, perhaps, walk or ride 
a considerable distance before show¬ 
ing noticeable evidence of their condi¬ 
tion. 

Profuse hemorrhage alone gives 
rise to symptoms denoting a grave 
lesion: rapidly progressive exsangui- 


134 


ABDOMINAL INJURIES (LAPLACE). 


nation or acute anemia; nausea or 
vomiting; weak, rapid, and some¬ 
times irregular pulse; dilated pupils; 
cold sweats; yawning, ending in con¬ 
vulsions and coma. Shock is likely 
to be progressive in these cases. 

The only symptoms that are 
present in practically all cases are 
pallor and vomiting: the accompani¬ 
ments of any severe blow on the 
abdomen, and therefore of no value 
whatever as differential signs. The 
temperature is of no assistance in 
these cases. 

The amount of “knock-out” after 
injuries such as will cause prolapse 
of the intestines is often surprisingly 
slight, subjects sometimes walking a 
considerable distance with such in¬ 
juries, with their intestines supported 
by a bandage. A man hit in the ab¬ 
domen may be quite unconscious that 
his intestine is prolapsed. Small mis¬ 
siles penetrating the bowel may cause 
very little immediate pain or disturb¬ 
ance; on the other hand, some men 
shot in the abdomen, or even the 
limbs, with a bullet or other small 
projectile, experience a tremendous 
blow or kick which may induce un¬ 
consciousness. Intense pain occur¬ 
ring promptly in wounds of the lower 
abdomen is especially connected with 
penetrating buttock wounds, and is 
valuable in calling attention to their 
dangerous nature. Apart from very 
extensive injury, the shock in abdom¬ 
inal wounds seems due, in great part, 
to loss of blood and, later, peritonitis. 
Some superficial lesions on the outer 
surface of the liver seem, however, 
to cause extreme shock, sufficient to 
cause death without marked blood 
loss. Stripping up of the retroperi¬ 
toneal tissue by blood causes dispro¬ 
portionate collapse, possibly on ac¬ 
count of sympathetic injury. A small 
injury causing great pain will produce 
pallor and collapse with cold extremi¬ 
ties, though the pulse be quiet and 
good. Cuthbert Wallace (Pract., 
Sept, 1916). 


DIAGNOSIS.—On general prin¬ 
ciples dangerous complications are to 
be expected when marked shock, 
nausea, vomiting, hiccough, anxiety, 
intense thirst (indicating a probable 
involvement of the peritoneum), and 
insomnia are present. Besides these 
indications there are others peculiar 
to each organ which greatly assist in 
establishing at least an approximately 
certain diagnosis. 

Intestines.—Bullets striking antero- 
posteriorly rarely cause more than 
four perforations, while oblique or 
transverse shots are likely to produce 
a much larger number of lesions: 
from fourteen to sixteen. On general 
principles, however, a penetrating 
wound may always be considered as 
having caused a lesion of the intes¬ 
tines. 

The most important symptom is 
the escape of intestinal gases and 
more or less fluid substances through 
the wound. The mere presence of 
emphysema around the wound is of * 
no value, however, since air is gener¬ 
ally forced into the wound by the 
bullet. 

The most experienced surgeons oc¬ 
casionally find more or less difficulty 
in diagnosing penetration and perfor¬ 
ation before operation, and all are, 
of course, opposed to precocious 
operating in non-penetrating wounds. 
An aperture of exit is not always 
present. Any missile may ricochet, 
and the writer has seen wounds in 
which, if the missile had traversed 
by the shortest route between the two 
openings, there would have been per¬ 
foration of many vital organs and 
structures; yet there was no serious 
injury. 

There are a few recognized rules 
to follow: The closer together the 
wounds of entrance and exit, the less 
the chance of penetration. According 
to Rochard, if there is persistent com- 


ABDOMINAL INJURIES (LAPLACE). 


135 


plaint of abdominal pain, perforation 
is almost certain; if a patient passes 
gas at the anus, there is no perfora¬ 
tion. Eastman (Amer. Med. Assoc.; 
N. Y. Med. Jour., Jan. 15, 1918). 

Pain is usually one of the first and 
most constant signs of injury to the 
abdominal contents, its character de¬ 
pending upon the amount of fluid 
escaping into the peritoneal cavity. 
Associated with pain is spasm of the 
abdominal muscles, especially the 
recti, which, even though slight, can 
usually be detected. Patients operated 
upon while in shock nearly always 
die, while in cases of active hemor¬ 
rhage they will die if not operated. 
The history and examination of the 
blood will help in the diagnosis, a 
leukocytosis being found in hemor¬ 
rhage but not in shock. McGuire 
(N. Y. Med. Jour., Sept. 21, 1921). 

Free hemorrhage from the wound 
tends to indicate an intestinal lesion; 
if the stools also contain blood the 
diagnosis may be considered as 
certain. 

Probes have been discarded in 
penetrating wounds, owing to the 
irregular course followed by the bul¬ 
let in many cases and the danger of 
creating a false passage. Digital ex¬ 
ploration of small wounds furnishes but 
little information, while in bullet 
wounds there is danger of pushing 
into the peritoneal cavity what for¬ 
eign substances may happen to be 
present. 

The majority of surgeons now favor 
enlargement by an incision at least 
two inches in length, intersecting the 
bullet or incised wound. Layer after 
layer of tissue is carefully dissected 
on each side of the track, the walls of 
which, in gunshot wounds, are usually 
darker than the normal tissues, owing 
to contact with the lead or powder- 
products of combustion. Using the 
grooved director to divide the tissues 


and the hemostatic forceps to grasp 
any bleeding vessel, the peritoneum 
is finally reached, when the certainty 
that a penetrating wound is present 
or not may be established. If prac¬ 
tised with strict aseptic precautions 
this procedure does not expose the 
patient. 

War injuries of the large intestine 
are serious from their infectivity 
rather than their multiplicity. They 
are often more difficult to find and 
repair than those of the small gut. In 
war, many extensive tears are caused 
by shell fragments, but a bullet may 
itself completely divide the intestine, 
as witnessed by Wallace in the case 
of the ascending, transverse, and de¬ 
scending colon, though not in the 
case of the pelvic colon. Many 
wounds are extraperitoneal or partly 
extra- and intra- peritoneal at the line 
of reflexion of the peritoneum of the 
colon. The latter variety of wound 
is often overlooked, in spite of care¬ 
ful search, and if found, is very hard 
to suture adequately. 

Stomach.—Hematemesis is a fre¬ 
quent symptom of penetrating wound 
of this organ and a much more 
valuable one than in contusion, since, 
in the latter, a slight laceration of the 
mucous membrane may produce it. 
The blood may be pure, but in the 
majority of instances it is mixed with 
partially digested alimentary semi¬ 
liquid material. If the wound is suffi¬ 
ciently large to allow the contents to 
escape through it the nature of the 
injury is, of course, clear, but an 
important complication is to be ap¬ 
prehended : extravasation into the 
peritoneal cavity capable of causing 
peritonitis. If this is circumscribed, 
adhesions are formed and the patient 
recovers. Frequently, however, gen- 


136 


ABDOMINAL INJURIES (LAPLACE). 


eral peritonitis follows, ending in 
death. Hence the importance of an 
early recognition of extravasation. 

Besides hematemesis and the pres¬ 
ence of gastric fluids, there are 
usually present in such injuries the 
marked symptoms witnessed in cases 
of contusion: rapidly progressive 
anemia, pallor, fluttering pulse, etc. 

Gastric wound cases show pain, sick¬ 
ness, collapse, abdominal rigidity, and 
tenderness, vomiting being especially 
pronounced, but .the - collapse less 
marked than usual. The respiration 
rate increases more rapidly in pro¬ 
portion than the pulse rate. Pain is 
worst when the pyloric or cardiac 
ends are involved, and collapse most 
marked in wounds of the curvatures. 
Fraser and Bates (Brit. Med. Jour., 
Apr. 8, 1916). 

The writer cites 2 instances in civil 
life where a single bullet made 3 per¬ 
forations in the stomach. This is 
due to the 3 contraction waves, each 
of which becomes quite deep as it 
passes toward the pylorus, thus mak¬ 
ing it possible for a bullet to graze 
or even perforate the tip of an in¬ 
verted crest as it passes through. N. 
Kerr (Ills. Med. Jour., xxxiii, 267, 
1918). 

Liver.— A wound of the liver gives 
rise to all the symptoms observed 
when a contusion has caused lacera¬ 
tion of the organ: Intermittent pain, 
radiating in various directions, espe¬ 
cially toward the shoulder, if the 
convex portion of the organ is torn, 
and in the direction of the waist, if 
the concave or inferior portion of the 
organ is the seat of injury. There is 
marked pallor, . superficial itching, 
and, later on, jaundice. The stools 
may be clay-colored, thus indicating 
the absence of bile. 

The hemorrhage varies in these 
cases according to the cause of the 
lesion; one caused by a bullet is 


prone to be accompanied by consider¬ 
able and frequently fatal bleeding.' 
Stab wounds, when the weapon is not 
large, do not give rise to considerable 
hemorrhage. A copious flow of blood 
from a wound in the hepatic xegion 
indicates that the liver is involved. 
The flow of bile through the wound 
is a valuable sign, but it is seldom 
that this secretion can be obtained 
alone, blood being usually mixed 
with it. 

Of 25 cases of hepatic injury occur¬ 
ring in New York hospitals, uncom¬ 
plicated by serious lesions of other ab¬ 
dominal organs, 12 were ruptures, 9 
gunshot wounds, 4 stab wounds. 
Eleven deaths resulted—a mortality 
of 44 per cent. (Tilton). 

Among 37 cases, the course of the 
missile was transverse in 21. Simple 
furrows often cause more trouble¬ 
some hemorrhage than perforating 
wounds. Shell wounds, usually ex¬ 
tensive, often cause secondary hem¬ 
orrhage, and are nearly always badly 
infected, necrosis and sloughing of a 
great part of the liver following, as 
a rule. With an open shell wound 
suppuration is the rule, but is of 
no great importance. Secondary ab¬ 
scesses, however, are a grave matter. 
Of the 37 cases, 25 showed compli¬ 
cating pleural injury; next came in¬ 
juries of the stomach. Seven cases 
showed no physical signs of liver in¬ 
jury. Secondary bleeding (4 cases) 
usually occurs about the tenth day 
and always means septic infection, 
which causes pain, distention, fever, 
and rapid, weak pulse. Twelve cases 
showed jaundice. Some form of bi¬ 
liary fistula—the most characteristic 
sign of liver injury—was present in 
15 cases, opening through the pleura 
in 7, all of which recovered. Of 25 
deaths from hepatic injury, 60 per 
cent, were due to sepsis and 40 per 
cent, to secondary hemorrhage. The 
chief lethal complication was hemo¬ 
thorax; 7 cases died from infection 


ABDOMINAL INJURIES (LAPLACE). 


137 


from the effusion. G. H. Makins 
(Brit. Jour, of Surg., iii, 645, 1916). 

In some instances extensive lacera¬ 
tions of various organs may give rise 
to no preliminary morbid phenomena. 
Thus, W. L. Robinson reported fatal 
cases of marked laceration of -liver 
and bowel in which there, was neither 
shock, hemorrhage, nor high pulse. 

Spleen.—In cases in which the 
spleen is wounded the diagnosis can 
easily be established by the location 
of the external opening and the direc¬ 
tion of. the track. As is the case 
in contusion, there is marked local 
pain and profuse bleeding, which, if 
the organ is greatly lacerated, may 
soon prove fatal. This is apt to 
occur after gunshot wounds at close 
range, the organ under such circum¬ 
stances becoming pulpified. Punc¬ 
ture wounds are less likely to produce 
fatal hemorrhage. Pain in the left 
shoulder has been considered a diag¬ 
nostic sign of value. 

The diagnosis of splenic wounds is 
always difficult. Almost never, in the 
first few hours after the injury, is 
there the least sign of bleeding, un¬ 
less there is a crushing injury with 
tear of the pedicle, causing death 
within a short time. On the second 
to the sixth day, as a rule, the pulse 
suddenly becomes frequent and weak, 
signs of anemia become marked, and 
the subject unexpectedly succumbs. 
Dullness in the splenic region or 
lower in the abdomen due to blood 
is inconstant and difficult to make 
out. Some splenic wounds exhibit 
symptoms of peritonitis. The diag¬ 
nosis is best based on the nature, site, 
and direction of the wound. Radio¬ 
scopy is significant if it reveals a 
foreign body that has penetrated to 
a depth of 7 to 12 centimeters from 
the posterior wall. Even in doubtful 
cases celiotomy is indicated, with 
splenectomy whenever practicable. J. 

Fiolle (Paris med., Aug. 25, 1917). 


As a rule, injury of the spleen can 
be merely suspected, as tears of the 
liver, pancreas, and mesentery often 
present the same symptoms. The 
general signs of internal abdominal 
injury are not, as a rule, well marked 
at first. A slight hematuria, due to 
simultaneous slight injury of the left 
kidney, may help in the diagnosis. 

It is better to operate once too 
often than once too late. The best 
incision is the median, for in internal 
hemorrhage any organ may be in¬ 
volved. If necessary, a transverse 
incision may be added. If there are 
tears extending deep into the paren¬ 
chyma the spleen should be removed. 
In superficial tears of the capsule it 
should be tamponed, as suture is al¬ 
ways unceitain. 

In all of his cases the writer col¬ 
lected the blood from the abdominal 
cavity, mixed it with 0.5 per cent, 
sodium citrate solution, and reinjected 
it intravenously. He thinks he 
thereby saved many lives. H. Hauke 
(Beitr. z. klin. Chir., cxxii, 389, 1921). 

Kidneys. — Symptoms frequently 
accompanying wounds of the abdom¬ 
inal organs—extreme pallor, weak 
pulse, cold extremities, nausea, and 
vomiting—are apt to be- most marked 
when, besides the organ itself, the 
peritoneum has been pierced. 

A wound of the kidney gives rise 
to severe pain in the majority of 
cases, but this symptom may be 
absent. As in cases of laceration, the 
pain radiates in various directions, 
especially in the direction of the ex¬ 
ternal genital organs. The testicle of 
the corresponding side, besides being 
the seat of considerable suffering, is 
frequently raised by spasmodic con¬ 
tractions of the scrotum. 

At first a' small quantity of bloody 
urine may be passed, but this is often 
followed by vesical tenesmus and 
complete retention, due to the pres¬ 
ence of clots in the bladder. 


138 


ABDOMINAL INJURIES (LAPLACE). 


Much information is sometimes ob¬ 
tained by a close examination of the 
wound of exit. If the track of the 
bullet be anteroposterior and the 
missile have entered from the front 
and penetrated the kidney, the exit 
wound will be found in the lumbar 
region. It is frequently found in this 
situation to contain urine, a positive 
indication that the organ or its annex, 
the ureter, has been wounded. 

In injuries of' the kidneys, simple 
perforations are often negligible. 
Hematuria, rarely severe or persist¬ 
ent, was observed in only 11 out of 
27 cases. Its degree in no way ac¬ 
cords with the severity of renal dam¬ 
age. External escape of urine was 
noted in only 7 cases. In 17 fatal 
cases, 7 were due to secondary hem¬ 
orrhage, which occurred in 12 in¬ 
stances, usually about the fourteenth 
day. In every case of secondary 
hemorrhage the urine was infected. 
The hemorrhage occurred either as 
a persistent hematuria or a perirenal 
hematoma travelling into the iliac 
fossa and along Poupart’s ligament, 
with skin ecchymoses and slight 
fever. Makins (Brit. Jour. Surg., iii, 
645, 1916). 

Cystoscopy was employed in a 
number of cases to determine loss of 
renal function and in latent cases, the 
presence of bladder injury. The X- 
rays were used to advantage to de¬ 
termine the presence of and locate 
accurately missile fragments. The 
complications seen included sepsis, 
secondary hemorrhage, and urinary 
fistula. The last occurs when there 
is a wound of the pelvis, or the tear 
in the parenchyma extends into the 
pelvis, or when the ureter is torn. 
The chief causes of death were sepsis 
and secondary hemorrhage. Of 42 
cases studied, 5 died. A. Fullerton 
(Brit. Jour, of Surg., Oct., 1917). 

The conditions which make an iso¬ 
lated kidney wound dangerous are 
hemorrhage and infection. In 46 
fresh kidney wounds severe hemor¬ 
rhage was observed in 6. In 3 of 


these cases where there was a con¬ 
comitant liver wound, the patients 
died. In 3 of the cases the hemor¬ 
rhage was a hematuria; 2 died with¬ 
in a few hours. In 5 cases a peri¬ 
renal hematoma was produced. Of 
35 remaining patients who showed 
no special symptoms necessitating 
immediate action, a primary opera¬ 
tion was done in 11 cases, a second¬ 
ary operation in 2, and abstention 
was observed in 22. The primary 
operation consisted either in a ne¬ 
phrectomy or in cleansing and drain¬ 
age of the trajectory. Of 3 nephrec- 
tomized cases, 2 died; of 4 tamponed 
patients, 3 died; 1 hematoma drained 
recovered; 5 clearance and drainage 
operations recovered; 22 abstentions 
from surgical intervention gave 3 
deaths and 19 recoveries. M. Chev- 
assu (Bull, et mem. Soc, de chir. de 
Paris, xliv, 81, 1918). 

If the wound of entrance be in the 
back, its location over the site of the 
kidney may suggest a lesion of the 
latter; but the urine test will only be 
of value if the projectile only pene¬ 
trate the kidney without perforating 
it. 

If it penetrate the organ, the ex¬ 
travasation will take place into the 
peritoneal cavity. The same will be 
the case if the missile enter from the 
front without going through the 
organ. Bullets buried in the renal 
parenchyma either become encysted 
or cause abscesses, and pass out 
through the ureters or into the ad¬ 
joining parts. 

Bladder.—The symptoms vary ac¬ 
cording to the location of the wound. 
A perforation between the symphysis 
and the peritoneum above does not 
give rise to general symptoms; 
whereas shock, pallor, weak pulse, 
vomiting, etc., may be much marked 
when the peritoneum is involved in 
the injury. In all cases, however, 
severe pain is experienced at the site 


ABDOMINAL INJURIES (LAPLACE). 


139 


of the lesion and radiating" to the 
thighs and testicles. 

The passage of urine soon becomes 
very difficult and spasmodic. It may 
be voided, drop by drop, for a long 
while, notwithstanding the efforts of 
the patient, then suddenly gush out 
for a few moments and again flow 
slowly. This symptom may be due 
to accumulation of clots or to spasm 
of the urethra. If the catheter is 
passed, hematuria becomes evident 
when the bladder has been pene¬ 
trated : a characteristic sign. 

As in the case of rupture due to 
contusion, infiltration may take place 
through the wound into the neighbor¬ 
ing tissues; any obstacle to the free 
passage of urine greatly encourages 
this. Hence the necessity, in all 
bladder lesions, of keeping the organ 
as free as possible by the frequent 
use of the catheter. 

The writer in a study of 53 cases 
calls attention to the comparative 
rarity of injuries of the bladder in 
warfare, the percentage of total 
wounds reaching the base being not 
more than 1 in 3000 or 4000. The 
bladder in a collapsed state occupies 
so little space that it forms a very 
small target for the missiles of war. 
Just before an attack the nervous 
tension presupposes an evacuation of 
the bladder contents. If the patient 
is caught unawares at other times, 
the organ may be in a state of dis¬ 
tention. The prostate because of its 
proximity to the neck of the bladder 
is frequently injured with it. 

In the 53 cases reported, the in¬ 
jury to the bladder was caused by 
bayonet in 2 cases; by shell in 24 
cases; by bullets (rifle or machine- 
gun) in 12; in 7 by shrapnel; in 1 
case indirectly by a shell and directly 
by a fall of earth on the abdomen; in 
7 cases the nature of the missile was 
unknown. In nearly 75 per cent., 
therefore, there was a wound in the 


buttock region reaching as far as, or 
actually penetrating, the bladder. 
The suprapubic route was compara¬ 
tively rare. 

The foreign body was retained in 
33 cases. In 10 it came to rest in the 
bladder. In the remaining cases it 
lodged in the pelvis or its walls, oc¬ 
casionally between the bladder and 
rectum. The entrance wound is fre¬ 
quently of small size and compara¬ 
tively insignificant on superficial ex¬ 
amination. The wound in the blad¬ 
der itself was of the most varied 
nature, a perforation, tear or slif, 
and in 1 case a considerable portion 
of the bladder wall had been shot 
away. 

The gravity of bladder injuries is 
greatly enhanced by associated dam¬ 
age to adjacent structures such as 
intestine or bone. Shock is likely to 
be present when other severe injuries 
complicate the case. According to 
Wallace, it is one of the chief causes 
of death at the clearing stations. 

Hemorrhage also contributes largely 
to the high mortality of such wounds. 
Leakage of urine is one of the most 
important complications. This may 
appear at the wound in the parietes, 
or be more or less concealed in the 
form of extravasation into cellular 
tissue or leakage into the peritoneal 
cavity. In cases reaching the base, a 
urinary fistula was most frequent in 
the region of the buttock. 

A sudden, sharp pain may occur 
when the bladder is struck, but when 
the patient reaches the base, this pain 
is not a constant feature. There is 
some tenderness and rigidity in the 
hypogastrium in a fair proportion of 
the cases. Vomiting is occasionally 
seen in cases in which the peritoneal 
coat is intact. On the other hand, it 
may be entirely absent in the first 
hours of an intraperitoneal lesion. 
As in most war wounds, fever is com¬ 
monly present, and depends largely 
upon the amount of infection in the 
soft parts and bone. 

The mortality in bladder wounds is 
rather high. Wallace states that in 
uncomplicated cases it is 56 per cent., 


140 


ABDOMINAL INJURIES (LAPLACE). 


and in complicated cases the picture 
is dismal in the extreme. In the 
writer’s series of 53 cases, the mor¬ 
tality was over 24 per cent. A. Ful¬ 
lerton (Brit. Med. Jour., vi, 24, 1918). 

PROGNOSIS. —Gunshot wounds 
are more fatal than stab wounds, but 
stab wounds, in which the peritoneum 
is penetrated, are fully as fatal as gun¬ 
shot wounds. 

The kind of weapon inflicting the 
injury plays an important role in this 
connection. A triple-edged bayonet 
is more likely to produce a serious 
laceration than a flat blade. Again, 
wounds caused by small weapons, 
such as a Flobert rifle, for instance, 
would hardly produce lesions to be 
compared to the old Enfield or Minie 
rifles, which sometimes caused a large 
portion of an organ to protrude 
through a wound of exit the size of 
an apple. 

Report of 44 cases of penetrating 
abdominal wounds, all in civil prac¬ 
tice. Of 6 cases without laparot¬ 
omy 4 died. Among 38 penetrating 
wounds the mortality was 45 per 
cent.; among 31 penetrating wounds 
of hollow viscera, 51.5 per cent.; 
among 25 gunshot wounds of hollow 
viscera, 60 per cent., and among 6 
stab wounds perforating hollow vis¬ 
cera, 16.3 per cent Of 7 cases of 
injuries of the liver, spleen, and other 
structures, with no involvement of 
hollow organs, 6 recovered. Stomach 
perforation occurred in 11 cases, with 
5 recoveries, and intestinal perfora¬ 
tions in 29 cases, with 15 recoveries. 
Randolph Winslow (Jour. Amer. 
Med. Assoc., Oct. 3, 1914). 

Portions of the solid viscera are 
sometimes cut off or shot off, leaving 
a gaping tear, which greatly com¬ 
promises the issue. Again, as is 
often the case with the liver, the 
bullet, or any foreign material 
dragged in by the latter, may lead to 


complications which greatly reduce 
the chances of recovery. 

An important factor is the time 
elapsing between the receipt of the 
injury and that at which competent 
treatment is applied in mild cases. 
This is especially true as regards the 
early utilization of surgical measures 
when these become necessary. The 
sooner these are instituted, the more 
favorable the prognosis, especially 
during the first ten hours. 

The relation between spontaneous 
cures and operative interference as 
worked out by Eisendrath is about as 
follows:— 

Spontaneous Recoveries. 



PER CENT. 

Spleen . 

. 15.8 

Liver . 

. 21.8 

Intestines . 

. 7. 

Kidney (extraperitoneal) . 

. 70. 

Kidney (intraperitoneal) . 

. 0. 

Bladder (intraperitoneal) . 

. 2. 

Bladder (extraperitoneal) . 

. 11. 

Operative Recoveries. 


PER CENT. 


56. (50 cases). 

59.5 (37 cases). 

48. (42 cases prior to 1896). 

50. (38 cases since 1896). 

80. 


100. ( 6 cases). 

52. (43 cases). 

30. (last 15 years).—Mitchell. 


In 1917, Rouvillois and 

his asso- 

dates presented the following figures 
concerning abdominal war wound 
cases treated in a French automobile 

surgical ambulance: — 


Recoveries. 


PER CENT. 

Small intestine (39 cases) . 

. 28.3 

Cecocolon (17 cases) . 

. 41.2 

Liver (7 cases) . 


Stomach (6 cases) . 

. 66.7 

Spleen (2 cases) . 


Hemorrhage is a great 

enemy of 

the wounded subject in 

abdominal 

wounds, owing to the fact that there 














ABDOMINAL INJURIES (LAPLACE). 


141 


is little tendency toward spontaneous 
arrest. Three or four hours after an 
injury small arteries in wounded 
bowel are still spurting vigorously. 
Hence the necessity and value of 
rapid transportation of these sufferers 
to a suitably equipped operating 
room. IL H. Sampson (Brit. Med. 
Jour., Apr. 11, 1916). 

Much bleeding occurs from injured 
gastric vessels, omentum, mesentery, 
retroperitoneal tissue, abdominal wall 
(deep epigastric artery), pelvic veins, 
liver, kidney, and spleen. The intes¬ 
tinal walls, on the other hand, do not 
bleed to any appreciable amount. 
Pallor and pulse are the best criteria 
as to the blood lost. If near a wound 
in the bowel, bleeding may aggravate 
the situation by carrying infection to 
distant parts of the abdomen. Retro¬ 
peritoneal infection may occur with 
or without a wound of the bowel; 
where the bowel is injured, the colon 
is usually the part implicated, the en¬ 
trance wound being on the flank or 
loin. From retroperitoneal gas infec¬ 
tion the peritoneum may be pushed 
forward as in retroperitoneal hemor¬ 
rhage; such cases are nearly always 
fatal. The operation site, too, be¬ 
comes badly infected in many in¬ 
stances of penetrating abdominal 
wound, the origin of acute infection 
being in the peritoneal cavity. Vir¬ 
ulent wound sepsis may occur even 
after a lesion of the small bowel has 
been successfully dealt with by the 
sufgeon. Death from peritonitis in 
abdominal wounds usually occurs on 
the third to fifth day, but may occur 
within 24 hours or in 10 days. The 
degree of bowel distention is a better 
prognostic guide than the amount of 
exudate present. Wallace (Pract., 
Sept., 1916). 

In abdominal wounds the mortal¬ 
ity, excluding moribund cases, was 
50 per cent. The total operative 
mortality was 54 per cent. That of 
hollow viscera, 65 per cent.; of stom¬ 
ach, 53 per cent.; of small intestine, 
66 per cent.; and of great intestine, 
59 per cent. 

Am,ong 263 abdominal wounds at 


an advance station, the patients oper¬ 
ated on between 1 to 6 hours after 
wounding were 43; recovered, 27, or 
62.8 per cent.; died, 16, or 37.2 per 
cent. Cases operated 6 to 12 hours 
after wounding, 33; recovered, 12, or 
36.3 per cent.; died, 21, or 63.7 per 
cent. Patients operated on between 
12 to 16 hours after wounding, 18; 
recovered, 3, or 16.6 per cent.; died, 
15, or 83.4 per cent. Patients oper¬ 
ated on over 24 hours after being 
wounded, 11; recovered, 5, or 45.4 per 
cent.; died, 6, or 54.6 per cent.; re¬ 
coveries at 48, 36, 33^2, 32 and 30 
hours, respectively. Wallace (Lancet, 
Apr. 28, 1917). 

Report on 263 cases of abdominal 
wounds encountered at a hospital 
stationed close up to the fighting line 
and thoroughly equipped for dealing 
with urgent surgical work. Recov¬ 
ered, 136, 51 per cent. Died, 127, 49 
per cent. Number admitted “with 
penetration,” 180. Number on whom 
a laparotomy was performed, 110. 
Recovered, 46, 41.5 per cent. Died, 
64, 58.5 per cent. Hughes and Rees 
(Lancet, Apr. 28, 1917). 

Of the patients who survive opera¬ 
tion performed in the first twelve 
hours a high proportion will have had 
their lives saved by it, and this is 
true in a lesser degree of those oper¬ 
ated on in the second twelve hours. 
After this time most of those who 
survive operation are those whose’ 
injuries were not originally fatal. 
Owen Richards (Brit. Med. Jour., 
Apr. 27, 1918). 

Report of the case of a man in 
whom a steel rod one-half inch in di¬ 
ameter and 54 feet long, in falling, 
entered the body just behind the left 
shoulder and emerged at the inner 
aspect of the right knee. After pass¬ 
ing through the posterior aspect of 
the left lung, the rod penetrated 
obliquely through the bodies of 3 or 
4 vertebrae in the lower dorsal and 
upper lumbar regions. Below this it 
could be felt below the pole of the 
right kidney and just behind the in¬ 
ferior vena cava. At this point it 
passed for about one-half inch into 


142 


ABDOMINAL INJURIES (LAPLACE). 


the peritoneal cavity without causing 
any damage, and again became extra- 
peritoneal by penetrating the psoas 
muscle. It appeared to leave the ab¬ 
dominal cavity by drilling a hole 
through the brim of the pelvis behind 
the acetabulum. Recovery from the 
shock was rapid. The upper end of 
the rod having been sterilized, trac¬ 
tion was applied in the direction of 
the curvature of the rod, which was 
thus slowly removed while a close 
watch was kept for internal hemor • 
rhage, etc. The resulting shock was 
great but yielded to treatment. Un¬ 
eventful recovery followed. Lake 
(Lancet, Apr. 23, 1921). 

Intestines.—The prognosis depends 
greatly, upon the nature of the lesions. 
Stab wounds opening the intestine 
lengthwise, if small, often heal of 
their own accord; transverse wounds 
are more serious, while complete sec¬ 
tion of the bowel is a very dangerous 
complication. Gunshot wounds show 
a great fatality. Prior to the intro¬ 
duction of antiseptic surgery the 
mortality exceeded 90 per cent.; since 
then, the mortality has been reduced 
to 40 per cent, or less in cases oper¬ 
ated during the first twelve hours. 
Perforated wounds of the descend¬ 
ing colon and sigmoid flexure are 
seldom fatal; those of the transverse 
colon give a worse prognosis, by the 
formation of fistulae, adhesions, and 
abnormal communications. Again, 
diatheses may compromise recovery. 

The authors noticed that the less 
the damage to the gut—when the 
lumen had been entered—the greater 
the likelihood of extensive peritoneal 
soiling; this is ascribed to the inhibi¬ 
tion of peristalsis in massive injuries, 
which is incomplete or absent in the 
lesser ones. Fraser and Bates (Brit. 
Med. Jour., Apr. 8, 1916). 

Infection of the small and large 
bowel exhibit a radical difference in 
that, whereas the former tend to 


spread progressively, the latter if un¬ 
disturbed, tend to become localized. 
As regards the small intestine, there 
does not seem to be much danger of 
infection in the first few hours, but a 
critical period would appear to be at 
the eighth to the twelfth hour. The 
infection does not usually result from 
extrusion of the bowel contents, for 
the viscus is generally empty and 
paralyzed, but probably from the 
carrying out of infection by the pro¬ 
jectile and the everted mucous mem¬ 
brane. For some hours the coils stay 
in the position in which they were 
when wounded. At a later period 
they are found, on the contrary, thin 
and distended, due to beginning in¬ 
fection. Small gut injuries, as a 
whole, arc serious from their multi¬ 
plicity. The lesions vary from a 
small perforation to complete divi¬ 
sion or destruction of a part of the 
bowel. Bomb wounds, small though 
often multiple, are favorable, usually 
lending themselves well to suture. 
Bullets cause all sorts of injuries, 
often as severe as those due to larger 
shell fragments. Wallace (Pract., 
Sept., 1916). 

Septic infiltration of retroperitoneal 
tissue seems a frequent lethal factor 
in large gut wounds. Wounds of the 
transverse colon are more apt to be 
multiple than those of the other 
divisions of this gut. Wounds of the 
rectum are divided into those compli¬ 
cating wounds of the buttocks, ischial 
fossae, or perineum, and those caused 
by missiles entering the lower ab¬ 
domen. With the former the great¬ 
est danger is septic absorption, but, 
on the whole, extensive buttock 
wounds do not do badly at the front, 
being widely open from the nature of 
the injury. 

With the abdominal type, severe 
multiple injury of the small bowel, 
and also injury of the bladder, are 
likely to accompany the rectal wound. 
Septic peritonitis is to be feared. 
Wallace (Lancet, Mar. 4, 1916). 

Stomach.—Uncomplicated wounds 
of this organ frequently yield without 


ABDOMINAL INJURIES (LAPLACE). 


143 


trouble when the bullet, blade, or 
other instrument causing the perfora¬ 
tion is small, especially if the stomach 
was empty at the time the injury was 
inflicted. The mucous membrane 
bulges out and forms a plug which 
obturates the hole until reparative 
processes have sealed the aperture on 
the peritoneal side. Complicated 
cases, in which the lesions are exten¬ 
sive, soon reach a fatal issue if de¬ 
prived of timely surgical intervention. 

Many cases of injury limited to the 
stomach have died, after successful 
suture, from the effects of primary 
gastric hemorrhage. The escape of 
food from the wounded stomach de¬ 
pends not only on the time of the last 
meal, but also on the size and situa¬ 
tion of the wound. If the wound is 
small and near the lesser curvature or 
cardiac end, little food escapes, while 
if it is large and near the greater 
curvature, marked extravasation may 
occur. 

Liver.—The prognosis of wounds 
of the liver depends mainly upon the 
complications. If the patient does 
not die from hemorrhage soon after 
the receipt of the injury, he is still 
exposed to the results of extravasa¬ 
tion into the peritoneal cavity, the 
presence in the liver of a foreign 
body,—the bullet and what material 
it may have forced into the wounds, 
—etc. Peritonitis, hepatitis, and ab¬ 
scess are, therefore, dangers to be 
taken into consideration. Hepatitis 
and abscess are much less to be 
feared, however, from stab wounds, 
no foreign body being left behind, 
unless, as in dueling, the sword-point 
strike the spinal column, causing the 
blade to break. In such an event, 
however, the hemorrhage would 
probably prove mortal very rapidly. 


As to mortality, the statistics of 
Edler, Mayer, and others show it to 
average about 50 per cent., including 
the cases attended by complications. 

The most extensive injuries to the 
liver are frequently not incompatible 
with life. One patient who recov¬ 
ered lost a transverse section of 
the entire upper abdominal wall some 
3 inches in width, with a groove in 
the liver substance which almost bi¬ 
sected it. The lower half of the liver 
was stitched into the defect in the 
abdominal wall. R. E. Skeel (N. Y. 
Med. Jour., Oct. 18, 1919). 

Spleen.—Slight punctured wounds 
of the spleen are not mortal unless 
complicated with laceration of a large 
artery. They are sometimes followed 
by abscesses which heal after a pro¬ 
longed period in the great majority 
of cases. Severe punctured wounds 
are dangerous in proportion, but, if 
the primary hemorrhage is not such 
as to cause an early fatal issue, the 
chances of recovery are about those 
of slight wounds. 

Gunshot wounds are much more 
serious as a result of rupture of the 
spleen taking place under the con¬ 
cussion. When the bullet is large 
and its velocity is great, fatal hemor¬ 
rhage quickly ensues. Rupture of 
the spleen may also occur during 
convalescence. 

During the War of the Rebellion 
the proportion of deaths was 93 per 
cent. In civil life, however, the 
weapons used are, as a rule, less 
powerful, and the mortality is much 
smaller. In the European war a mor¬ 
tality as low as 37.5 per cent, in 8 
cases was reported by Duval. The 
predilection of this organ for abscess 
tends to compromise recovery. 

Kidneys.—Complications are also 
to be feared in lesions of this organ. 


144 


ABDOMINAL INJURIES (LAPLACE). 


namely: peritonitis, nephritis, and 

secondary hemorrhage. Again, the 
position of the kidney makes it prob¬ 
able that other organs are also injured 
in the majority of cases. The direc¬ 
tion from which the bullet or stab 
came, the length of the penetrating 
blade, etc., are important factors 
when the nature of the injury is to 
be determined. 

Bladder.—Gunshot wounds of the 
bladder are always serious as far as 
complications are concerned, rectal, 
vaginal, perineal, and scrotal fistulae 
being very frequent. 

As to the mortality of penetrating 
wounds of the bladder, it is not so 
great as in lesions of any of the other 
abdominal organs. Stab wounds are 
more frequently mortal than uncom¬ 
plicated bullet wounds, the propor¬ 
tions being 29 per cent, in the former 
and 17 per cent, in the latter. When, 
however, osseous lesions are also 
present, penetration or fracture of 
the pelvis, etc., the mortality reaches 
29 per cent. 

TREATMENT. —The preliminary 
measures indicated in the treatment 
of complicated contusions of the 
abdomen are also applicable in that 
of penetrating wounds of that cavity. 
Protrusion of portions of the intes¬ 
tines, the mesentery, and the omen¬ 
tum through the external wound is 
an early complication met with in 
many cases of penetrating wound. If 
the protruding mass be intestinal and 
in good condition it should at once be 
returned into the abdomen. An easy 
way of accomplishing this (recom¬ 
mended by Levis) is to raise the 
middle of the patient’s body by means 
of a pillow, the hands, etc., while he 
is lying on his bock. The anterior 
portion of the pelvis is thus separated 


to an abnormal degree from the 
anterior portion of the thorax, and 
the increased room in the abdominal 
cavity thus obtained causes the intes¬ 
tines to spread out, as it were, and, 
their weight causing traction upon 
the protruding loop, the latter quickly 
slips in. 

At times the accumulation of gas 
or fecal matter checks its inward 
progress; the gas can easily be let 
out by inserting a clean hypodermic 
needle into the projecting bowel; the 
fecal matter can also be reduced in 
quantity by drawing out an addi¬ 
tional portion of the gut—thus in¬ 
creasing the size of the loop—and 
gently pressing small portions of the 
contents into the unprolapsed bowel, 
thus diminishing the tension of the 
protruded mass. It is sometimes 
necessary tO' enlarge the abdominal 
wound. If the projecting mass be 
greatly inflamed the latter procedure 
is unavoidable. If it be gangrenous 
it had better be incised and the forma¬ 
tion of a fecal fistula permitted. 

An omental protrusion, if healthy, 
can be immediately returned, but if 
greatly inflamed or gangrenous it 
should be transfixed near the abdom¬ 
inal wall and tied with a double liga¬ 
ture ; then excised. The stump is 
then secured in the deeper portion of 
the wound with ligatures and adhe¬ 
sive strips. 

Punctured wounds of the abdomen 
are frequently recovered from spon¬ 
taneously, owing to the absence of 
serious visceral lesions. The same 
statement may be made as re¬ 
gards bullet wounds, but with less 
emphasis. 

Of serious abdominal injuries 20 
per cent, are hopeless, and of the re¬ 
maining 80 per cent., not less than 


ABDOMINAL INJURIES (LAPLACE). 


145 


60 per cent, should recover after early 
operation under proper conditions. 
Rutherford Morison (Oxford War 
Primers, 1915). 

Surgeons are agreed that wounds of 
the small gut area should be ex¬ 
plored. There is still some doubt, 
however, about cases of suspected 
stomach injury and of wounds appar¬ 
ently involving the colon. Wounds 
limited to the liver furnish most of 
the cases of undoubted penetration 
which it is advisable to leave alone; 
the kidney and spleen furnish a few 
of these. While hemorrhage is itself 
a sufficient reason for operation, espe¬ 
cially if the case is seen early and the 
bleeding presumably continuing, the 
many cases presenting a single entry 
of a missile, particularly in the back, 
buttocks, thighs, and lower thorax, 
without signs of bleeding, are per¬ 
plexing to the surgeon. If the latter 
does not feel justified in operating on 
principle, he must watch the pulse 
and the abdominal rigidity. 

As a rule, within 4 or 5 hours the 
abdomen will harden or the pulse 
rise above 100, or both, if the intes¬ 
tine has been wounded, thus indicat¬ 
ing operation. In lower thoracic 
wounds the abdominal rigidity must 
be discounted, but in suspicious thigh 
and buttock wounds, rigidity and 
rapid rising pulse are urgent signals 
for operation. Single wounds of the 
posterior aspect of the flanks present 
many difficulties. Since a median in¬ 
cision to explore the small bowel in 
such cases may lead to dissemination 
of a previously local infection about 
the colon, possibly the best course 
is a local exploration through a 
transverse loin incision, or a careful 
watch for abdominal involvement. 
With regard to stomach wounds, 
Wallace favors routine operation on 
account of the danger attending hem¬ 
orrhage from vessels supplying this 
organ. Withholding operation, the 
favorable moment for dealing with 
this hemorrhage may be passed be¬ 
fore the signs of anemia appear; or, 
there may be associated lesions of 
other organs that will prove fatal. 


Cuthbert Wallace (Pract., Sept., 
1916). 

Report on 56 non-military cases of 
stab and gunshot wounds of the ab¬ 
domen, mostly revolver wounds. 
Severe lacerations of internal organs, 
such as are observed in war wounds, 
were not found. There were 35 per¬ 
forating wounds with injuries to in¬ 
ternal organs, with 8 deaths, and 10 
perforating wounds without injury 
to internal organs and 11 non-per¬ 
forating wounds without any deaths. 

Immediate, careful transport of the 
patient should follow the application 
of a compression bandage. Every 
wound of the abdominal wall should 
be widened as early as possible in 
order that it may be determined 
whether the peritoneum is involved. 
If so, laparotomy is indicated. 

The positive indications for opera¬ 
tive treatment are; (1) Extrusion of 
abdominal organs; (2) escape of 
gastro-intestinal contents or urine 
from the external wounds; (3) severe 
anemia, with an increasing zone of 
dullness indicating severe hemor¬ 
rhage; (4) X-ray demonstrations of 
the escape of gas into the peritoneal 
cavity. W. Smital (Wien. med. Woch., 
Ixx, 653, 1257, 1305, 1442, 1501, 1547, 
1601, 1920). 

When surgical measures become 
necessary, including enlargement of 
the wound, the patient should be 
placed under an anesthetic. The 
rectum should be emptied by copious 
injections containing a tablespoonful 
of glycerin to the pint. A subcu¬ 
taneous injection of morphine 
grain) is generally recommended. 
Rectal injection of whisky and warm 
water, 2 ounces of the former and 4 
of the latter, is useful to sustain 
cardiac action. It may be repeated in 
an hour if evidences of impending 
shock are still present. In patients 
with nervous shock or severe hemor¬ 
rhage, camphorated oil, ether, and 
saline injections with %o grain (0.001 
■10 


146 


ABDOMINAL INJURIES (LAPLACE). 


Gni.) of adrenalin have proven useful. 
Intravenous saline infusion may be 
continued during the operation. 

It is deemed necessary to get the 
patient thoroughly warm before op¬ 
eration, and to minimize shock in 
every way, the room being well 
heated and the table provided with a 
hot water bed. The writers advise 
operating these cases in the Trendel¬ 
enburg position. Just before begin¬ 
ning, subcutaneous saline administra¬ 
tion is started, and this is continued 
throughout the operation, 3 or 4 pints 
of fluid being thus given. Hender¬ 
son’s closed ether anesthesia is pre¬ 
ferred. Fraser and Bates (Brit. Med. 
Jour., Apr. 8, 1916). 

A pulseless patient never benefits 
by operation. A total absence of 
pulse, however, must not be con¬ 
founded with an extremely rapid 
pulse, which perhaps cannot be 
counted. Such patients may be 
snatched from death by operation. 
A truly pulseless patient must be 
treated first and every effort made to 
bring back the arterial tension; while 
with a patient who still has a pulse 
no time should be lost in ligating 
large blood-vessels and removing pos¬ 
sible causes of sepsis. Operation 
within three hours has shown a su¬ 
periority over longer periods. Pa¬ 
tients with very little traumatic 
shock and otherwise in good condi¬ 
tion are practically certain to recover 
after very early intervention. Vaquez 
has shown that after ordinary lapa¬ 
rotomy, a blood-pressure of 140 may 
be lowered to 100. Operation on a 
patient with a tension below 100 is 
inevitably followed by death inside of 
twelve hours. Below 100, the lower 
the tension the worse the outlook. 
It should be 120 and upward before 
one can feel certain of recovery. 
Quenu (Bull. Med., Oct. 28, 1916). 

The efficient treatment of gunshot 
wounds involves the 2 principles of 
antisepsis and osmosis. These 2 prin¬ 
ciples, according to the writer, are 
fulfilled by a combination of equal 
parts of ichthyol and glycerin which 


he has been using in various military 
and civil hospitals for nearly 3 years. 
It is particularly efficient in wounds 
that refuse to heal under classic 
measures. Duggan (Pract. June, 1918). 

If, after a careful examination of 
the enlarged wound, it is found that 
the peritoneum is not involved, the 
exposed tissues are carefully cleansed 
and the wound is closed, deep sutures 
being used to hold the tissues in ac¬ 
curate apposition. As already stated, 
the possibility of ventral hernia 
should be borne in mind: the patient 
should be kept in bed for some time 
and a bandage be worn until all local 
weakness has disappeared. 

If the lesion is intraperitoneal, a 
median incision of good size should 
always be used. 

The presence of gas indicates a 
lesion of the intestinal canal, requir¬ 
ing examination of the whole canal, 
with closure of each hole as it is 
reached. 

All drains should be removed at 
the end of 36 to 48 hours. The 
wounds should be closed with 
through and through sutures of silk¬ 
worm gut, as closure can thus be 
more rapidly done. The patient 
should be placed in the Fowler po¬ 
sition and proctoclysis immediately 
instituted. Morphine and atropine 
are prescribed as required. If undue 
vomiting occurs the stomach should 
be washed out No attempt to move 
the bowels should be made for 3 or 
4 days. F. W. McGuire (N. Y. Med. 
Jour., Sept 21, 1921). 

If, after a stab wound, the parietal 
peritoneum alone is found incised or 
penetrated and there is no evidence 
that the organs behind have suffered 
injury, the tissues must be cleansed 
with great care and the peritoneal 
flaps brought together, the serous 
surfaces being kept in contact. A 
continuous catgut suture is used for 
the peritoneum; the muscles and skin 


ABDOMINAL INJURIES (LAPLACE). 


147 


are then united and the wound is 
closed. The measures already out¬ 
lined to prevent ventral hernia are 
also indicated for the deeper wound. 

When laparotomy becomes neces¬ 
sary the incision should be made in a 
spot affording the operator the great¬ 
est opportunity for a wide field of 
action, and should be sufficiently 
long. When performed for the arrest 
of dangerous hemorrhage, a long 
median incision will enable the sur¬ 
geon to reach any organ with ease: 
an important factor, for the missile or 
blade inflicting the injury may have 
traversed harmlessly between several 
coils of intestine and have caused a 
rent in the organ most remote from 
the point of entrance. Again, the 
incision should be free, so as to make 
it possible to easily reach all parts of 
the abdomen to allow of a thorough 
removal of all extravasations which 
might otherwise ultimately cause 
complications. 

As the late Nicholas Senn taught, 
one of the important elements of suc¬ 
cess in the treatment of gunshot and 
stab wounds of the stomach is time. 
Unnecessary time lost in finding and 
suturing the visceral wounds is a 
source of immediate danger to life 
which should be eliminated as far as 
possible by means which enable the 
surgeon to make a quick and correct 
diagnosis, and by resorting to a 
method of suturing which closes the 
wound safely and securely with the 
least possible delay, and which leaves 
it in a condition most favorable for 
speedy definite healing. It is well 
known that small penetrating wounds 
of the stomach often heal without 
operative intervention. By contrac¬ 
tion and relative displacement of the 
different muscular layers of the thick 


wall of the stomach the tubular 
wound is contracted and obstructed 
sufficiently to prevent leakage until 
the canal on the peritoneal side 
becomes hermetically sealed by firm 
plastic adhesions which prevent ex¬ 
travasation during the time required 
for the repair of the visceral wound. 
If in larger wounds of the stomach 
the same degree of occlusion can 
be accomplished by the simplest me¬ 
chanical means, then such a pro¬ 
cedure should take the place of the 
more time-consuming methods of su¬ 
turing now in general use. This can 
be accomplished with the purse-string 
suture. 

In gunshot injuries the defect in 
the stomach-wall is circular and the 
wound-margins contused; hence the 
deep sutures could at first furnish a 
barrier to the escape of stomach-con¬ 
tents only for a short time, as their 
hold in the necrosed tissues would 
be imperfect and only of brief dura¬ 
tion. In short round wounds the cir¬ 
cular suture is the one which will 
bring and hold together in permanent 
uninterrupted contact the serous sur¬ 
faces in the most efficient manner. In 
the treatment of gunshot wounds of 
the stomach the principal object of 
suturing should be to close the per¬ 
foration in such a way as to guard 
securely against extravasation, and at 
the same time approximate and hold 
in apposition a maximum surface by 
intact healthy peritoneum. This is 
accomplished by making a cone of 
the injured part of the stomach with 
the apex corresponding with the 
wound directed toward the lumen of 
the organ. The purse-string suture 
applied in the manner that will be 
described in the experimental part of 
this section will maintain this cone 


148 


ABDOMINAL INJURIES (LAPLACE). 


until the healing of the visceral 
wound has advanced sufficiently to 
render further mechanical support 
superfluous. The cone on the mucous 
side of the stomach acts in the manner 
of a valve, which in itself is an ef¬ 
fective barrier against the escape of 
stomach-contents, while the circular 
suture constitutes almost an absolute 
safeguard against leakage, and brings 
in contact the serous surfaces in the 
interior of the cone. For wounds of 
the posterior wall of the stomach the 
author recommends a purse-string 
suture of heavy durable catgut to be 
applied through the anterior wound. 
The anterior wound is closed with a 
purse-string suture of silk of medium 
size applied to the base of the cone on 
the serous side. It is desirable that 
the circular suture should cause no 
necrosis of the included tissues. By 
using an absorbable suture in closing 
the posterior wound in the interior of 
the stomach this object is gained, as 
only a small part of the thickness of 
the stomach-wall is subjected to pres¬ 
sure, and the tension caused by the 
ligature is gradually lessened by sof¬ 
tening of its material, and is entirely 
removed by the absorption and diges¬ 
tion of the ligature in less than three 
weeks. 

The wound of the posterior wall of 
the stomach is found and made ac¬ 
cessible by inserting through the an¬ 
terior wound a grasping forceps with 
which the posterior wall is seized at 
a point where, from the course of the 
bullet, the second wound is supposed 
to be located. Through a wound 
large enough to admit the index finger 
the greater part of the posterior wall 
of the stomach can be made acces¬ 
sible to sight, and touch, and the 
perforation can be located and closed 


with the purse-string suture in a few 
moments. In doubtful cases inflation 
of the stomach should invariably be 
practised for the detection of a second 
and possibly a third perforation. 

The experiments demonstrated the 
safety of the circular suture in the 
treatment of gunshot and other pene¬ 
trating wounds of the stomach. All 
of the animals operated upon in 
this manner recovered and the repair 
of the injuries as shown by the 
specimens are ideal. The absence of 
adhesions over the posterior wound 
and their constant presence over the 
anterior wound indicate that the 
presence of the silk ligature and the 
needle punctures were the causes of 
the circumscribed plastic peritonitis 
which produced them. In none of 
the specimens could any indications 
be found of necrosis of any of the 
inverted tissues, and included in part 
by the circular suture. 

In the course of three weeks the 
continuity of the mucosa at the seat 
of the injury was completely restored. 
The result of these experiences has 
convinced the author that the circular 
suture compares favorably with the 
methods of suturing in general use, 
and besides has the great advantages 
over them in the case of its applica¬ 
tion and the saving of much valuable 
time. 

Suturing of the posterior wound 
by partial eversion of the stomach 
through the anterior obviates un¬ 
necessary handling of the organ and 
the necessity of interfering with the 
vascular supply incident to exposure 
of the posterior wound, as is done by 
the methods most generally practised. 
If extravasation into the retrogas- 
tric space has taken place, flushing 
through the posterior wound and a 


ABDOMINAL INJURIES (LAPLACE). 


149 


vertical slit in the gastrocolic liga¬ 
ment and gauze drainage through the 
latter are invariably indicated. 

The stomach and the transverse 
colon are best brought to view by an 
incision through the rectus muscle. 
In the case of the stomach hernia of 
the mucous membrane will facilitate 
recognition of the lesion. The as¬ 
cending colon requires lateral incision 
on the right side, and the descending 
on the left. These also should be 
sufficiently long to facilitate the 
search for the injury or injuries that 
may be present in the organ itself and 
beyond. 

In cases seen later, when perito¬ 
nitis has already set in, a small supra¬ 
pubic incision for insertion of a tube 
to the bottom of the pelvis, with the 
Fowler position, will give the patient 
a chance of recovery. Mayo-Robson 
(Brit. Med. Jour., Dec. 4, 1915). 

The incision may be such as to 
intersect the wound of entrance. This 
is desirable at all times, the aim 
being, of course, to always avoid un¬ 
necessary solutions of continuity. 
Such an incision can fortunately be 
made in many of the cases in which 
the hemorrhage is not formidable. 

In abdominal cases where there is 
much blood, the authors quickly swab 
it away with a long roll of dry gauze 
before examining the viscera. In 
early cases with extensive peritoneal 
soiling they wash out the peritoneal 
cavity; in later cases, and those with 
signs of peritonitis, they do not. 
Drainage by a single Keith’s tube 
passing into the pouch of Douglas 
proves sufficient; in special instances 
local or flank drainage is necessary. 
Fraser and Bates (Brit. Med. Jour., 
Apr. 8, 1916). 

Experience in 356 cases showed 
that for injuries of the small intes¬ 
tines either pursestring suture or re¬ 
section should be employed, the for¬ 
mer being given preference wherever 


possible. When resection is required 
end-to-end anastomosis seems to give 
better results than lateral and is more 
rapid. Extravasated material is best' 
removed by mopping with gauze 
wrung out of hot saline. Saline 
should never be used for lavage of 
the abdominal cavity. Lockwood, 
Kennedy, Macfie and Charles (Brit. 
Med. Jour., Mar. 10, 1917). 

No important change in the tech¬ 
nique of operation in gunshot wounds 
of the abdomen was introduced dur¬ 
ing the war, except that it became 
the rule to close without drainage. 
A drain often leads to infection. Fre¬ 
quently all layers of the abdominal 
wall were closed but the skin, as late 
infections often resulted from the 
latter. If a drain is used at all, it 
should be a loose gauze drain. The 
mortality in gunshot abdominal 
wounds was extremely high,' but this 
mortality occurred largely on the 
field as a result of hemorrhage and 
shock. J. H. Gibbon (N. Y. Med. 
Jour., June 28, 1919). 

Hemorrhage.—When the abdom¬ 
inal cavity is opened and the hemor¬ 
rhage, which is usually more venous 
than arterial, is marked, the blood 
rapidly accumulates in the most de¬ 
pressed portion of the cavity from an 
invisible source. To mop out the 
blood with sponges is generally rec¬ 
ommended ; but such a procedure does 
not cause the hemorrhage to cease,— 
the first desideratum. In these formi¬ 
dable cases an assistant should at 
once introduce his hand through the 
wound—hence the advisability of a 
long incision—and compress the ab¬ 
dominal aorta below the diaphragm. 
This procedure immediately checks 
the flow. 

If any difficulty is experienced, the 
digital pressure upon the aorta may, 
for an instant, be decreased, and a 
sudden gush will point to at least the 
direction from which the blood comes. 


150 


ABDOMINAL INJURIES (LAPLACE). 


The necessary steps are then taken to 
arrest the flow, and the abdominal 
aorta is released as soon as possible, 
—not suddenly, but by a gradual re¬ 
duction of pressure. 

The measures to be employed in 
arresting hemorrhage vary according 
to the organ involved. Gunshot 
wounds of the liver are frequently 
stellate, and rents, radiating from the 
bullet-track in various directions, 
greatly increase the bleeding surface, 
the parenchyma in this organ taking 
part to a great degree in the emission 
of blood. To force resilient sponges 
into these tears is to increase their 
depth. If the wound be not very ex¬ 
tensive, it may be sutured with catgut 
or cauterized with the actual cautery. 
If the wound is extensive it had better 
be packed with long strips of iodo¬ 
form gauze, one end of which is 
brought out of the external wound. 

Of 5 cases in which projectiles 
were extracted from the liver. In 
only 1 was the projectile removed 
Immediately after the injury. In the 
other four it had remained in the liver 
for from 10 to 23 months. 

In all cases the extraction was done 
under the control of the radioscopic 
screen. 

In but 1 instance was the opera¬ 
tion indicated by the symptoms of 
secondary infection; in the others the 
indication was furnished by the pain 
caused by the projectile. In 1 case 
the extraction was done by the 
lumbar route; in the others, by 
laparotomy. 

The incision in the liver varied 
from 1 to 3 cm. in length according 
to the size of the projectile. The pro¬ 
jectile was removed with the forceps. 
In no case was there any extensive 
hemorrhage, but in 1 instance a pyo¬ 
pneumothorax developed, following 
the operation. L. Sauve (Bull, et 
mem. de la Soc. de Chir. de Paris, xlv, 
1461, 1919). 


The spleen is next in order as to 
profuseness of hemorrhage. The 
same procedures may be adopted as 
for the liver, but the introduction of 
iodoform strips is to be preferred. If 
these means fail, splenectomy is the 
only measure left. 

Sometimes a portion of the organ 
projects through the wound; removal 
of the protruding portion should be 
practised after passing a ligature 
around the mass. 

The walls of the stomach and intes¬ 
tines may also give rise to marked 
hemorrhage notwithstanding their 
comparative thinness. The number 
of vessels coursing through them, 
however, is very great. In these 
cases it is best to hem the margins 
of the wounds with fine silk. The 
bladder may be treated in the same 
way. 

The mesentery sometimes bleeds 
profusely when perforated. The 
mesenteric vessels should be ligated 
en masse with fine silk. 

Blood escaping through bullet holes 
in the bowel gradually works its 
way downward into the small pelvis 
and is not absorbed. Often an 
abscess forms, and later walling-off 
adhesions are broken down and 
secondary peritonitis results, usually 
extremely serious. There are two 
ways to render harmless the infected 
extravasated blood: (1) When the 
patient is seen in the first twenty- 
four or forty-eight hours a very 
small laparotomy incision is made 
above the symphysis (under local 
anesthesia) just large enough for a 
rubber drain the size of the finger, 
to be carried down into the small 
pelvis. The patient keeps in a half¬ 
sitting position or lies on his side. 
(2) When not seen until later, the 
space between the rectum and the 
bladder must be carefully examined 
through the rectum. If there is any 
tenderness, protrusion, tenesmus or 


ABDOMINAL INJURIES (LAPLACE). 


151 


difficulty in micturition, the region is 
opened up at once. Payr (Miinch. 
med. Woch., Aug. 18, 1914). 

Report of the case of a man who 
had received 2 stab wounds, 1 
through the costal cartilage of the 
left side and 1 in the right thigh. At 
operation the peritoneal cavity was 
found full of blood, and an incised 
wound on the stomach was bleeding. 
This was closed by a double row of 
Lembert sutures. Shock, secondary 
anemia, and collapse followed, and 
the patient continued to vomit blood, 
also developed evidences of pneu¬ 
monia. Bayliss’s gum acacia solution 
and blood transfusion, however, 
turned the tide, and he ultimately re¬ 
covered. C. W. Bowie (Jour. Royal 
Army Med. Corps, Apr., 1921) 

Hemorrhage of the kidney is ar¬ 
rested in the majority of cases by 
iodoform-gauze package. If this 
should prove ineffectual the organ 
must be exposed and the vessels tied 
if possible. If not, nephrotomy or 
nephrectomy should be resorted to. 
The latter operation does away with 
the chances of complication attending 
the former, while the kidney of the 
other side assumes the function of 
both. 

For extraperitoneal injuries of the 
anterior aspect of the bladder, if high 
and if after regularization they can 
be correctly sutured, the practice 
should be suture with a permanent 
catheter. If the lesion is in the vicin¬ 
ity of the neck, suture should not be 
tried. The practice should be cystos- 
tomy as high as possible and a cath¬ 
eter placed after an interval. For 
intraperitoneal injuries, if in the apex 
or the posterior aspect, resection of 
the margins is indicated, suturing in 
two places with fine catgut, and a 
permanent catheter. The Douglas 
sac should be closed by a row of 
sutures, thus isolating the wound 
from the rest of the abdominal cavity, 
to be followed by cystostomy. As 
wounds of the fundus are usually 


produced by perineal projectiles, they 
necessitate a lateral perineotomy or 
even a transverse, made as wide as 
possible so that a loose tamponade in 
contact with the bladder wall may be 
instituted. H. Brin (Bull, et mem. 
Soc. de Chir. de Paris, xliii, 1086, 
1917). 

Of 43 bladder wounds met with 
since the beginning of the war, 6 ran 
a benign course. Such are usually 
bullet wounds; shell wounds show 
marked tears and easily produce a 
septic condition. In 15 cases there 
was a vesico-intestinal fistula, with 12 
spontaneous recoveries without oper¬ 
ations in a period varying from a few 
weeks to four months. Lesions of 
the pelvic girdle were observed in 29 
cases. A foreign body required re¬ 
moval in 12 cases. Treatment should 
be immediate and include disinfection 
of the tract, removal of fragments of 
bone, etc., and extraction of foreign 
bodies. The cavity should be thor¬ 
oughly explored both by radiography - 
and radioscopy; if these are not avail¬ 
able, every other known method of 
surgical exploration should be uti¬ 
lized. It seems necessary as soon as 
possible, sometimes on the first day, 
to make a suprapubic cystostomy. 
The indwelling catheter in such cases 
is only a makeshift. In all cases 
where an early operation was done, 
recovery followed; but, even when 
done later, drainage was good and 
cicatrization was hastened. F. Le- 
gueu (J. d’urol. med. et chin, Paris, 
vii, I, 1917). 

War wounds of the bladder are 
grave, but surgery and the retention 
catheter generally bring the men 
through. All of 29 patients recovered 
except 3, 2 succumbing to their ex¬ 
tensive wounds and 1 dying later 
from tetanus. Immediate suprapubic 
cystostomy is necessary when the 
wound has involved the peritoneum 
or rectum or both, and when the an¬ 
terior wall has been perforated. 
With a wound in the lower part of 
the bladder, drainage perfect, there 
is no need for immediate cystostomy 
unless fever and retention call for it. 


152 


ABDOMINAL INJURIES (LAPLACE). 


Under other conditions the author 
prefers cystotomy; he deprecates fur¬ 
ther any attempt to suture the blad¬ 
der wall at once unless the wound is 
intraperitoneal. Cathlin (Lyon chir., 
Jan.-Feb., 1918). 

Perforation.—The fact that the in¬ 
testines are, at times, perforated in 
twenty spots by a bullet suggests the 
considerable degree of care that 
should be given to this part of the 
procedure, which is carried out in the 
following way: The perforation 

nearest the rectum having been de¬ 
tected, the portion of intestine per¬ 
forated is gently brought into full 
view. An assistant causes the gas in 
the portion of gut below the lacera¬ 
tion to escape through the latter by 
slight pressure. This being done, the 
next step is to ascertain whether 
there is another perforation above. A 
fresh, aseptic glass tube is placed at 
the end of the insufflating tube and 
introduced into the wound with the 
tip directed away from the rectum^ 
The assistant now being directed to 
compress the intestine below the per¬ 
foration, a small amount of gas blown 
above the latter will inflate the upper 
segment if there is no opening, or 
indicate the location of the perfora¬ 
tion if there is one. As soon as the 
latter is detected, the tube is with¬ 
drawn, the neighboring intestine on 
each side of the first perforation is 
disinfected, and the opening is closed. 
This procedure is renewed until all 
perforations have been found and 
closed. 

This general plan renders unneces¬ 
sary the removal of the intestines 
from the abdominal cavity during 
any part of the operation, the source 
of complications in many cases, and 
of death by aggravated shock in 
others. 


Penetrating abdominal wounds 
made by rifle bullets are very deceiv¬ 
ing. Many of these patients are 
brought in apparently in very good 
condition; they are able to walk and 
are not in pain. If nothing is done 
for them, often within twenty-four 
hours, they will have developed gen¬ 
eral peritonitis from a small leakage 
in the intestinal tract, and they can¬ 
not then be saved by any method. 
These patients should be subjected to 
operation at once if the wound is 
clearly penetrating, and many times a 
perforation is found where least ex¬ 
pected from the symptoms. The dis¬ 
tended stomach may have a perfor¬ 
ating wound within its walls and 
should be carefully explored in all 
such cases. Patients having wounds 
of the liver usually recover unless 
there is too much destruction of tis¬ 
sue. Bleeding from these wounds is 
controlled by gauze packs. If it is 
difficult to control bleeding from the 
spleen, or if this organ is badly trau¬ 
matized, splenectomy seems prefer¬ 
able to an attempt to repair. In 
wounds of the intestine, it seems 
much safer to repair the wound 
whenever possible rather than resect 
the intestine. Penetrating wounds of 
the intestine, unless operated on 
early, have given a very high mor¬ 
tality. E. S. Judd (Journal-Lancet, 
Nov. 1, 1918). 

The manner of closing the wound 
is that indicated for lacerations fol¬ 
lowing blows. The stomach and in¬ 
testinal perforations being treated in 
the same way, the margins of the 
wound are turned inward and the 
serous surfaces are united by a con¬ 
tinuous, fine-silk Lembert suture or 
by interrupted sutures, including the 
serous and muscular coats and the 
submucosa. These are cut short and 
left in, being eventually discharged 
per anum. 

In simple suture of the small gut 
the wound must be small, with edges 
undamaged and mesentery intact. 


ABDOMINAL INJURIES (LAPLACE). 


153 


Wounds by bomb fragments are ideal 
for suture. The wound edges were 
not excised, and linen thread was em¬ 
ployed. Resection and anastomosis 
are indicated in the event of many 
perforations, extensive injuries, and 
mesenteric involvement. Fraser and 
Bates (Brit. Med. Jour., Apr. 8, 1916). 

Small round perforations may be 
closed with a single purse-string 
suture of silk or linen. In larger 
ragged wounds, a running suture is 
efficient in securing accurate closure 
of the serosa over the defect. In 
extensive tangential lacerations, ap¬ 
plication of the running Lembert 
suture should be preceded by closure 
of the wound with a simple running 
suture traversing the entire thickness 
of the gut wall. In wounds at the 
mesenteric border, care must be 
taken that the perforation in the 
muscular coat of the intestine itself 
is closed. After turning in the mus- 
cularis and mucosa of the gut at the 
site of perforation with Lembert su¬ 
tures, the opening in the mesentery 
is closed with a simple running su¬ 
ture. Complete division of the gut 
requires circular suture anastomosis 
or invagination of the ends with 
lateral anastomosis. The latter is the 
safer and amounts eventually to cir¬ 
cular suture since the gut at the 
junction straightens out and assumes 
a nearly normal conformation. J. R. 
Eastman (Jour. Ind. State Med. 
Assoc., Nov., 1917). 

Discussing thoraco-abdominal in¬ 
juries involving penetration of the 
diaphragm, with damage to subjacent 
viscera, the writer states that the re¬ 
pair of injuries to the diaphragm 
should be immediately carried out or 
else the diaphragmatic injury is en¬ 
larged so as to deal with intra¬ 
abdominal complications. There are 
well-defined limits to the amount of 
work that can be performed upon 
the viscera of the upper abdomen, for 
with reduction of herniated viscera 
and repair of injuries to the liver, 
spleen, portions of the cardiac end of 
the stomach, and occasionally the 
colon, very little further operative 


manipulation can be carried out. For 
injuries lower down in the abdomen 
it is necessary to supplement the 
thoracic technique with a laparotomy. 
Suturing of the diaphragm is com¬ 
paratively simple, and after the first 
suture is tied it is utilized as a trac¬ 
tion suture, and the remaining por¬ 
tion of the diaphragm readily sutured 
with a lock-stitch of No. 2 chromic 
catgut. C. G. Heyd (Trans. Amer. 
Assoc. Thoracic Surg.; Med. Rec., 
Apr. 16, 1921). 

At times the tissues around a per¬ 
foration are sufficiently contused to 
render an omental graft necessary. 

Enterectomy is sometimes required, 
and not infrequently exsections of the 
intestine are necessary. In that case 
the intervening portion, if it is not 
too long, had better be resected, thus 
avoiding a double operation in the 
continuity of the gut. 

After the active measures described 
have been carried out the extravasa¬ 
tion of the contents, of the stomach 
or intestines may make it necessary 
to flush the peritoneal cavity. Warm, 
sterilized water should be used, but 
care should be taken not to handle 
the intestines roughly. By turning 
the patient on his side the fluid is 
poured out. The abdominal cavity is 
then dried with large sponges wrung 
out of warm, sterilized water. Chill¬ 
ing of the viscera should be carefully 
avoided, and the parts should be 
exposed to the air as short a time as 
possible. 

Drainage is sometimes necessary, 
especially for wounds of the solid 
viscera, such as the liver, spleen, 
kidneys, etc., in which active meas¬ 
ures were not resorted to early. The 
weight of evidence, however, stands 
in favor of dispensing with drainage 
whenever it is possible. In bad in¬ 
fection large drainage tubes may be 


154 


ABORTION (WRIGHT). 


inserted into the flanks as well as the 
pelvis. 

Twenty-five cases of recto-colic 
rupture due to compressed air were 
collected by the writer. The symp¬ 
toms are those due to intestinal rup¬ 
ture and shock. Of the 16 cases 
operated on, life was saved in 7, in¬ 
cluding the author’s 2 cases. The 
operative mortality is therefore 57 
per cent. 

When the intestinal perforations 
are multiple, as is usually the case, 
and when the intestine is reduced 
to its mucosal coat alone, suture is 
useless. 

If the condition of the patient is 
poor, the intestine should be brought 
to the surface and fixed to the ab¬ 
dominal wall to form an artificial 
anus. If this is not possible, an 
enterectomy with a colo-colic or 
colo-rectal anastomosis is indicated. 
In the writer’s cases such anastomo¬ 
sis was impossible because of the 
condition of the rectum. The upper 
stump of the colon was therefore 
fixed to the abdominal wall as a per¬ 
manent artificial anus. Both patients 
made good recoveries. G. Jean 
(Presse med., xxix, 675, 1921). 

To summarize: we will say that 
immediate exploration of the abdom¬ 
inal cavity is indicated as soon as it 
is suspected to have been penetrated 
or in any way injured by a trauma¬ 
tism. The injury to its contents 
must then be repaired under strict 
aseptic precautions. 

Should no lesion be found, the 
mere exploration should result in no 
serious damage. 

After-treatment.—Food should be 
withheld for thirty-six hours, but a 
little water and brandy, in teaspoon¬ 
ful doses, may be allowed, especially 
if there is any degree of shock. In 
that case it is advisable also to use 
stimulants by the rectum or sub¬ 
cutaneously. Nutritive enemata of 


beef-tea and milk are necessary to 
sustain the patient’s powers. 

Proctoclysis of normal, salt solu¬ 
tion according to the Murphy gradual 
method should be resorted to. The 
head of the bed should be raised to 
apply the Fowler principle favoring 
the gathering of secretions / in the 
pelvis, where the absorption is less 
rapid. 

During this procedure no food 
should be given by the mouth. If 
the patient is weak, rectal alimenta¬ 
tion is indicated. In the less severe 
cases liquid food may be permitted 
by the evening of the second day, and 
soft, easily digested food after a week, 
rectal alimentation being continued 
until then. 

The sutures can be removed on 
the ninth day. The closure of the 
external wound must be complete 
before the patient can be allowed to 
leave his bed, and the danger of a 
ventral hernia should be counter¬ 
acted by means of an abdominal 
supporter. 

Hypodermic injections of strych¬ 
nine, Yqq to &i*ain, three times a 
day, according to indications, will 
prove most effectual in maintaining 
the strength of the patient and toning 
the muscular wall of the intestine. 

Ernest Laplace, 
Philadelphia. 

AB ORTI ON.— DEFINITION. 

—Ahortiofi is the expulsion or removal 
of the fructified ovum before the fe¬ 
tus is viable,—meaning by the term 
“viable” that the fetus has reached 
such a stage of development that it 
can live, thrive and grow after birth. 
We cannot say definitely when the 
fetus reaches that stage, but it has 
been the custom to consider that it 


ABORTION (WRIGHT). 


becomes viable at the end of the 
seventh lunar month or the twenty- 
eighth week of pregnancy. 

Still, a very young fetus may breathe 
after delivery. This occurred, for ex¬ 
ample in 3 cases (2 in the fifteenth 
and 1 in the nineteenth weeks, re¬ 
spectively) reported by Glockner. In 
the first of these there were six re¬ 
spiratory movements before and five 
after severing the cord, the fetus 
living one hour. In the second case 
the fetus lived an hour and a half and 
breathed five times. The third fetus 
lived but half an hour and breathed 
eight times. The autopsy showed air 
in the stomach, but the lungs were 
empty. 

From a clinical standpoint, how¬ 
ever, the fetus is not viable before the 
end of the seventh calendar month. 

Premature labor or delivery means 
the termination of pregnancy between 
the end of the seventh month and full 
term. In certain cases it is difficult to 
distinguish between late abortion 
and early premature labor. 

As to the time of occurrence, it has 
seemed convenient to consider two 
varieties: early abortion, when it 

occurs before or about the end of the 
third month of pregnancy, and late 
abortion, when it occurs between the 
latter part of the third month and the 
end of the seventh month of preg¬ 
nancy. 

Three varieties as to the methods 
of occurrence are also recognized: 
the spontaneous, when the abortion 
occurs without any outside interfer¬ 
ence, and is caused by some abnormal 
condition of the mother or fetus; the 
accidental, when the abortion is due to 
accident; and the induced, when the 
abortion is produced artificially by 
interference from outside. Induced 


155 

abortion is deemed legitimate when 
it is produced by a physician for just 
cause. The cause is considered just 
only when the abortion is induced to 
save the mother’s life which otherwise 
is imperiled. When the abortion is 
induced without such just cause, that 
is, when it is done for improper 
or immoral reasons, whether by the 
mother or the professional abortionist, 
it is known both from a medical and 
legal standpoint as criminal abortion. 

In the author’s clinic during the 
past 6 years, in a total of 5500 cases, 
he has had to perform abortion only 
31 times. Again, although 134 women 
came to the clinic for therapeutic 
abortion as follows: (1) of their own 
accord, 55; (2) sent by physicians, 
72; (3) sent from the intern clinic, 
4; (4) sent from the obstetric dept. 3, 
only 30 had to be operated upon. 

The author holds that at least two- 
thirds of the therapeutic abortions 
performed by private physicians are 
not indicated and are unnecessary 
when the cases are dealt with by 
skilled obstetricians. This is the evil 
practice that must be suppressed. 
On no account should therapeutic 
abortion be included among legiti¬ 
mate obstetrical operations. 

There is scarcely any agreement 
among competent physicians as to 
the causes which are strictly indica¬ 
tive of induced abortion. In every 
case where an abortion is considered 
a consultation should be held with a 
special internist who would not be 
concerned with the pregnancy but 
with the absolute condition of the 
woman as to concomitant disease. 
The author recognizes that 80 per 
cent, of abortions have their initiative 
from the woman herself. G. Winter 
(Zeit. f. Gynak., Jan. 6, 1917). 

Criminal abortion, according to the 
writer, a professor in the university 
law department, should be classed 
with espionage, counterfeiting, an¬ 
archy, etc., as the crime against 
society is more important than the 


156 


ABORTION (WRIGHT). 


individual character of the crime. 
The birth-control propaganda should 
be suppressed, as the arguments in 
favor of birth control apply also to 
voluntary abortion. Criminal abor¬ 
tion cases should not be given a jury 
trial, as the jurymen do not realize 
the social danger of the crime, and 
they yield to intimidation by the 
abortionists, usually powerful and 
always with a protecting backing. 
Another point which he emphasizes is 
that a physician cited in a suit for 
criminal abortion should be relieved 
of the ban of professional secrecy, so 
that his testimony can be used against 
the abortionists. Berthelemy (Bull, 
de I’Acad. de Med., Paris, Sept. 4, 
1917). 

The writer deprecates the modern 
tendency to enlarge the indications 
for induced abortion. The medical 
indications have still more been rein¬ 
forced by social and economic con¬ 
sideration, without speaking of the 
pressure brought to bear on the 
medical man by the patient’s relatives 
when pregnancies are too frequent. 
Of 202 cases sent to his clinic for 
therapeutic abortion, only 59 were 
performed there in the lapse of 5 
years. The reason for this condition 
of affairs is due to a change in 
ethical ideas in Germany. Bumm 
(Berl. klin. Woch., Jan. 7, 1918). 

As to frequency, it is impossible to 
estimate even approximately the pro¬ 
portion of pregnancies terminating in 
spontaneous abortions. Women who 
object to having large families have 
such a multitude of expedients to 
cut short their pregnancies, and fre¬ 
quently conceal their methods so 
carefully, that our estimates as to 
percentages cannot be exact. From 
the results of our experience in private 
practice it is indicated that abortion 
occurs from accident or spontaneously 
in 1 out of 10 pregnancies, that is, 
10 per cent. However, if we include 
induced abortions (legitimate and 


criminal), it is probable that abortion 
occurs in 3 out of 10 pregnancies, that 
is, in 30 per cent. 

The figures of the Paris Maternite 
from 1897 to 1905, as collected by G. 
Rimette, show 9875 pregnancies, 1457 
abortions, 627 spontaneous abortions, 
414 complicated abortions, 367 in¬ 
fected abortions, and 27 deaths from 
abortion. 

Michailofif, who bases his figures on 
257,988 births in one of the Russian 
maternities, found that the proportion 
of abortions to full-term deliveries 
was about 1 to 10. Keyssner, in his 
polyclinic material, found 469 abor¬ 
tions to 2623 confinements, or 1 
to 5.6. 

Miscarriage .—We consider abortion 
and miscarriage are synonymous 
terms. In former times the terms 
were not considered so, nor are they 
now in some quarters. Many, if not 
all, of the Rotunda men, and some 
obstetricians of North America, still 
use the term miscarriage in the old- 
fashioned way. According to them, 
miscarriage is a term applied to the 
expulsion of the ovum between the 
beginning of the fourth and the end of 
the seventh month, that is, between 
the time of the complete formation of 
the placenta and the time that the 
fetus becomes viable. Those who 
thus define miscarriage say that abor¬ 
tion is the term applied to the expul¬ 
sion of the ovum before the end of the 
third month, that is, before the forma¬ 
tion of the placenta has been fully 
completed. 

SYMPTOMS. —The symptoms of 
abortion are hemorrhage, a brown 
discharge after the death of the ovum, 
pains in the pelvis, complete or partial 
dilatation of the o-s uteri, expulsion of 
the whole or part of the ovum. 


ABORTION (WRIGHT). 


157 


The hemorrhage in the majority of 
abortions is not profuse, and may 
continue a long time. In a certain 
class of cases, however, the hemor¬ 
rhage is very profuse and sometimes 
causes death. 

Some obstetricians think that hemor¬ 
rhage in early abortion is never pro¬ 
fuse enough to cause death. Cer¬ 
tainly the hemorrhage before the 
formation of the placenta is seldom 
dangerous to life. There are excep¬ 
tions to this rule, however; but, so far 
as we know, the majority of the 
fatalities from hemorrhage in early 
abortion occur in cases of criminal 
abortion where sharp or pointed in¬ 
struments are used. 

In considering the symptomatology 
of abortion, however, it is very im¬ 
portant to obtain a clear conception of 
the two varieties commonly recog¬ 
nized, viz.: the “threatened” and the 
“inevitable.” 

[The importance of this distinction as¬ 
serts itself in connection with treatment. 
In the case of threatened abortion we are 
in doubt as to whether the uterus will be 
emptied or not, and our treatment aims at 
controlling the influences which are pro¬ 
ducing the symptoms of abortion, such as 
hemorrhage and uterine contractions. In 
the case of inevitable abortion the con¬ 
tents of the uterus will be held or partially 
expelled by nature’s efforts, and we pursue 
a line of treatment entirely different from 
that adopted for threatened abortion. 
Our aim now is to assist nature in expel¬ 
ling the contents of the uterus as soon as 
possible with safety to the mother. A. H. 
Wright.] 

The symptoms of threatened abor¬ 
tion are hemorrhage, pelvic pain and 
perhaps a slight dilatation of the os, 
especially in multiparae. The hemor¬ 
rhage, as already mentioned, is com¬ 
paratively slight in a large proportion 
of cases, and may continue for nine or 
ten weeks or longer without ending 


in actual abortion. The pains which 
are caused by uterine contractions 
may be fairly severe and may con¬ 
tinue for some time without causing 
the expulsion of the ovum. 

In inevitable abortion there are also 
hemorrhage, pelvic pains and more 
or less dilatation of the os, but these 
phenomena are more severe and pro¬ 
nounced. It is sometimes, in fact, 
very difficult to decide when an abor¬ 
tion becomes inevitable. Probably 
the safest guide is the hemorrhage. 
If the fetus is dead, or if the mem¬ 
branes are ruptured, abortion is also 
deemed inevitable. No definite line of 
demarcation can be established in this 
regard. 

The symptomatology of abortion 
varies, of course, to a certain extent 
according to the time at which it 
occurs. As carefully collated by Lu- 
taud, of Paris, the symptoms at the 
different periods are briefly as fol¬ 
lows :— 

Abortion During the First Month. 
—This usually gives rise to symptoms 
simulating those of retarded menstru¬ 
ation. Slight pains in the back in the 
region of the uterus are complained 
of; the symptoms, in this particular, 
resemble those of normal labor, but 
are very much less marked. Blood, 
blood-clots, and flakes of the mucous 
membrane of the uterus are gradually 
expelled during several days. The 
ovum is expelled entire, but it is so 
small that it is discovered, as a rule, 
with great difficulty. 

Abortion During the Second Month. 
—Inasmuch as the uterus has de¬ 
cidedly increased in size as compared 
with its size in the first month, the 
contractions and pains are compara¬ 
tively stronger. The embryo is usu¬ 
ally expelled inclosed in the unbroken 


158 


ABORTION (WRIGHT). 


membranes. Sometimes, however, 
the latter are ruptured. 

The embryo and membranes may 
be detached from the uterus in two 
ways:— 

(a) By hemorrhage between the 
membranes and the uterus, followed 
by uterine contraction. 

(b) By contraction of the uterus, 
followed by hemorrhage. In the lat¬ 
ter case the abortion is more pro¬ 
longed, the membranes being de¬ 
tached but slowly from the uterus. 

If the embryo be still living, the 
abortion lasts longer, and the hemor¬ 
rhage is greater. If the embryo be 
dead, the whole is usually expelled 
like a foreign body, and without rup¬ 
ture of the membranes. 

Examination of the uterus will 
show that it is increased in volume 
and situated lower down in the pelvis 
than normally. The cervix is dilated, 
softened, and filled with blood-clots. 
The dilatation is more marked in 
multiparae than in primiparae. 

The cervix, though dilated, does 
not. become effaced, and the embryo 
contained in the unruptured mem¬ 
branes may pass through the cervix 
and be expelled. If the membranes 
are ruptured, however, the embryo 
passes by itself, the very thin umbili¬ 
cal cord breaks, and the cervix closes. 
The membranes are, in this latter 
case, expelled later on. The mem¬ 
branes are ruptured about once in 
every 2 cases. 

Abortion from the Beginning of the 
Third to the End of the Fourth 
Month.—This occurs nearly always in 
two stages, the first consisting in the 
expulsion of the fetus, and the second 
in the expulsion of the membranes 
and placenta. 

The cervix in this form of abortion 


tends to diminish in length. The 
uterine contractions act more power¬ 
fully than in the previous forms of 
abortion. Under their influence the 
membranes are ruptured and the fetus 
is expelled. 

The placenta may still be adherent; 
the cervix then closes again, and 
the placenta and membranes are ex¬ 
pelled later on. Hemorrhage is likely 
to accompany the delivery of the 
placenta and membranes, especially 
when the former is only partly de¬ 
tached. Under these circumstances 
each uterine contraction is accompa¬ 
nied by hemorrhage. 

The placenta may be already de¬ 
tached when the fetus is expelled; in 
such a case it is likely to be expelled 
immediately after the latter, before 
the cervix closes, but part of the 
decidua may remain in the uterus 
after delivery of the placenta. ^This 
occurs most frequently when the 
fetus is dead. 

Statistics show that retention of the 
placenta occurs most frequently dur¬ 
ing this period. 

Abortion During the Fifth and 
Sixth Months.—The fetus and pla¬ 
centa are almost always expelled sep¬ 
arately. Uterine contraction is more 
marked; the cervix tends to become 
more effaced and to dilate. 

Delivery of the placenta usually fol¬ 
lows delivery of the fetus rapidly, and 
the tendency to hemorrhage is less 
marked than in the previous forms of 
abortion. 

Of 501 cases of abortion analyzed 
by Varnier and Brion, the fetus, or 
embryo, and the placenta were ex¬ 
pelled separately in 453, and together 
in 48 cases. When the delivery oc¬ 
curred in two stages, the time found 
to elapse between the expulsion of the 


ABORTION (WRIGHT). 


159 


fetus and that of the placenta was as 
follows: 120 cases, within 15 min¬ 
utes; 81 cases, from 15 to 30 minutes; 
78 cases, from 30 to 60 minutes; 83 
cases, from 1 to 4 hours. 

Whenever the placenta and mem¬ 
branes are not expelled within four 
hours after the expulsion of the fetus, 
or embryo, there is retention of the 
membranes and placenta. 

Abortion may take place suddenly, 
or resemble, in that particular, the 
irregular periodicity of normal labor, 
with more or less hemorrhage. It 
may, indeed, last several days, owing 
to weakness of the uterine contrac¬ 
tions or adhesions to the uterus or 
retention in the cervix of the masses 
to be expelled. (Rokitansky, Schii- 
lein.) 

Sudden or rapid abortion is frequent 
during the first two months; when 
the expulsion takes place after the 
third month it generally presents the 
characters of normal delivery. 

The menstruation returns earlier 
after abortion than after a normal 
labor. Englander, in a recent (1906) 
study of 57 cases of abortion, under¬ 
taken to ascertain the period of their 
first subsequent menstruation, found 
that in 64.9 per cent, the menses re¬ 
appeared in four weeks; in five weeks 
in 14 per cent. The remainder varied, 
1 patient going as long as six weeks 
after the abortion before menstru¬ 
ating. After labor, it is usually six 
to eight weeks before patients men¬ 
struate. 

DANGERS. —Just as parturition 
may be attended by deviations from 
the normal, so may abortion. 

Retention of the placenta occurs fre¬ 
quently. The latter is sometimes ex¬ 
pelled safely after some days, either 
entire or in pieces, but prolonged re¬ 


tention exposes the patient to hemor¬ 
rhage, toxemia, and septicemia. When 
completely detached, though retained, 
the placenta gives rise to no hemor¬ 
rhage, but if only partially detached 
such is not the case and copious hem¬ 
orrhage may thus be produced. 

In 15,000 cases of abortion studied 
by Seegert, fever occurred in 15 per 
cent. Of 633 patients, 182 had chills 
before they came under active treat¬ 
ment. Among the 15,000 patients 
were 450 who were severely infected; 
of these 94 died. In 82 cases autopsy 
was made. Those cases showed the 
most severe symptoms in which the 
longest time elapsed before the uterus 
was completely emptied. Fever often 
ceased when the uterine contents 
were expelled. 

The general symptoms that follow 
hemorrhage (a weak pulse, vertigo, 
fainting, etc.) occur only when the loss 
of blood has been severe. Under these 
■conditions septicemia, as evidenced by 
fetid lochia, chills, and high tempera¬ 
ture, is a probable complication. En¬ 
dometritis, salpingitis, and peritonitis 
have also been witnessed under such 
conditions. Tetanus is also another 
possible complication of these cases. 
Sterility commonly follows induced 
abortion. 

The writer observed 8 cases of 
sterilization, the result of induced 
abortions. All the women were mar¬ 
ried, in good health and none over 35 
years of age. In each instance the 
abortion was induced soon after the 
first period had been missed, usually 
the second or third week. The abor¬ 
tions induced in these women were 
as follows: 3 had been relieved 5 
times in 2 years; 2 six times in 2^4 
years; 1 woman 9 times in 3 years; 
1 woman 11 times in 5 years; 1 
woman 14 times in 5 years. In later 
years when these women desired to 


160 


ABORTION (WRIGHT). 


have children they found themselves 
sterile. They cheerfully submitted to 
treatments which buoyed them with 
hopes from month to month, only to 
find that at the end of their course 
of treatment they were just as sterile 
as they were before they consulted 
the gynecolog-ist. Reder (Trans. Amer. 
Assoc, of Obstet. and Gynec.; N. Y. 
Med. Jour., Nov. 23, 1918). 

ETIOLOGY AND PATHOGEN¬ 
ESIS. —There has been much theoriz¬ 
ing- as to the causes of abortion, and 
in many instances, the explanations 
and complicated classifications vouch¬ 
safed have obscured the subject in¬ 
stead of elucidating it. 

In a study of 164 instances of 
abortion, out of 563 patients exam¬ 
ined, the writer found that more than 
20 per cent, probably over 25 per 
cent., were induced. Sixty per cent, 
of all induced abortions result in 
more or less permanent sterility. 
These are worst when caused by the 
midwife, the patient herself, and last 
by the physician. A positive Wasser- 
mann is obtainable in about 25 per 
cent, of all women who have aborted. 
Less than one-third of these give any 
history or show any physical signs 
of the disease. Syphilis interrupts 
pregnancy at any and all periods of 
gestation, and in more than 60 per 
cent, of pregnancies. Renal defi¬ 
ciency does it only in the event of 
renal decompensation at any period 
of gestation. G. D. Royston (Amer. 
Jour, of Obstet., Oct., 1917). 

It is generally recognized that the 
causes may be of maternal, paternal, 
and fetal origin.. 

The causes of abortion may be 
classified as follows: 1. Criminal 
provocation, direct or indirect. 2. 
Maternal, such as constitutional dis¬ 
ease, pelvic disorders, affections of 
the nervous system, etc. 3. Paternal, 
such as certain constitutional dis¬ 
eases, chief of which is syphilis, and 
old age. 4. hTtal, such as death of 
the fetus and diseases of the placenta. 


It is generally supposed that 50 per 
cent, of abortions are criminally pro¬ 
voked. Titus found 82 per cent, of a 
series of criminal abortions at the 
Johns Hopkins Clinic were incom¬ 
plete, and 78 per cent, of this same 
series were infected, streptococcus in¬ 
fections occurring in 34.3 per cent, of 
these cases. 

Under the maternal, paternal and 
fetal causes of abortion, syphilis is 
the most frequent cause. In 657 
syphilitic women there were 35 per 
cent, of abortions. 

Decidual endometritis is a cause of 
abortion in 52 per cent, of infected 
and 68 per cent, of uninfected cases, 
while retroposition is a cause in 30 
per cent, of the cases. Lacerations of 
the cervix and pelvic floor account 
for 14 per cent, of all abortions. Can¬ 
cer and intra-uterine tumors are fre¬ 
quent causes. Poisons in the mater¬ 
nal blood from fevers such as small¬ 
pox, scarlet fever, typhoid and the 
like, are frequent causes of abortion, 
as are affections of the nervous sys¬ 
tem, as chorea, epilepsy and shock. 
Epidemic abortions caused by the 
bacillus abortus of Bang and strepto¬ 
cocci have been reported. 

The causes referable to the fetus 
include all the many diseases of the 
placenta, death of the fetus, and 
syphilis. The paternal causes include 
mainly syphilis, gonorrhea, albumin¬ 
uria, lead poisoning, and old age. J. 
E. Davis (Jour. Mich. State Med. 
Soc., xvii, 2, 1918). 

Maternal Causes.—Most cases of 
abortion are generally attributed to 
traumatisms, falls, blows—a cause not 
infrequently met with in the slums— 
the likelihood of premature delivery 
being decreased in proportion as the 
blow or other injury is remote from 
the region of the uterus. Operations, 
even sometimes when insignificant, 
have produced abortion. The so- 
called “aborting habit’’ is also recog¬ 
nized as a potent factor in this con¬ 
nection ; but this expression doubtless 


ABORTION (WRIGHT). 


161 


covers, in most instances, some hid¬ 
den and probably removable cause. 

The predominating cause, however, 
according to statistics, is syphilis, to 
which are attributed over one-fourth 
of the cases. When it is contracted 
before conception, abortion occurs re¬ 
peatedly—early when the infection is 
of recent date, but gradually nearer 
term as the contamination is more 
remote. There comes a time, there¬ 
fore, when normal delivery becomes 
possible. 

The prevailing view that syphilis is 
a prominent factor in the causation 
of abortion has been denied by Tren- 
chese and others. In a summary of 
679 cases of abortion at the Michael 
Reese Hospital the writer also found 
that syphilis was an etiological factor 
in but 4 per cent, of abortions. Lack- 
ner (Surg., Gynec. and Obstet., xx, 
537, 1915). 

In a study of the causes of abor¬ 
tion 563 patients were examined. A 
history of abortion was elicited in 
178. The 164 selected for detailed 
study gave a grand total of 664 preg¬ 
nancies, 348 of which ended in abor¬ 
tion. Criminal abortion was the 
most common factor in the series; 

51 out of 164 women having con¬ 
fessed to an induced labor, many re¬ 
peatedly. These 51 women had in 
all 220 pregnancies of which more 
than half, namely 118 (52.4 per cent.) 
resulted in abortion. Of these 118, 

84 (71.1 per cent.) were frankly 

acknowledged to have been induced. 
Comparing the percentage of induced 
abortions with the abortions in his 
entire material, the writer arrived at 
the figure 23.8 per cent. Only 20 
(39.2 per cent.) produced living chil¬ 
dren after having had abortions in¬ 
duced. Only 10 out of the 51 pa¬ 
tients had normal genital organs; the 
remaining 41 were more or less per¬ 
manently disabled. Among the 164 
cases, 46 gave a positive Wassermann 
and 5 patients with definite histories 
gave negative reactions after having 

1—11 


been treated. The writer holds that 
abortions are caused by syphilis 
much more frequently than the medi¬ 
cal public realizes. Royston (Amer. 
Jour, of Obstet., Oct., 1917). 

Next in order are malpositions and 
inflammatory disorders and tumors of 
the uterus and its adnexa, including 
ovarian cysts. Laceration of the cer¬ 
vix has recently attracted attention as 
a cause of abortion. The tear may be 
limited to the cervix, or it may extend 
upward to the body of the organ ; or 
again the rupture may occur above 
the external os. 

Charpentier refers to three distinct 
local uterine conditions in. otherwise 
healthy women: 1. Ill-developed uter¬ 
us ; the muscular coat does not read¬ 
ily soften, yet remains very irritable. 
Rare. 2. Displacements, especially 
flexions. Spur at the angle of flexion 
hypertrophies interferes with uterine 
development. 3. Congestion of the 
body and cervix, due to idiosyncrasies. 
Endometritis. 

Debilitating influences of various 
kinds, such as insufficient food, ex¬ 
cessive physical labor or fatigue, men¬ 
tal and physical shock, the abuse of 
alcohol, tobacco (women employed in 
cigar, cigarette, etc., factories), car¬ 
bonic oxide (as shown by the frequent 
occurrence of abortion in cooks) and 
lead, including paternal intoxication 
by this metal, tend also to bring on 
miscarriage. 

Great shock or injury is sometimes bet¬ 
ter borne by pregnant women than fre¬ 
quently repeated shock, e.g., the use of 
the sewing machine with the foot. Davis, 
has reported cases illustrating the fact 
that motoring during the early months of 
pregnancy is frequently followed by 
abortion. The danger seems to lie in the 
fact that the rapid motion of a motor car 
subjects the patient to many small, fre¬ 
quent jars. The characteristic of abortion 


162 


ABORTION (WRIGHT). 


following motoring is its slow and in¬ 
sidious development without bright hemor¬ 
rhage or pain. These abortions are, as a 
rule, incomplete, and require curetting. 
While motoring is dangerous in early 
pregnancy, in the later months of gesta¬ 
tion and with reasonable precautions as 
to smoothness of roads and moderation of 
speed it may prove exceedingly useful. 
Editors. 

Debilitating diseases have also been 
found to induce it. Influenza, in 
which the general adynamia is 
marked, has been recorded as a cause. 
In Asiatic cholera, abortion is almost 
invariably produced. 

The view that Bacillus abortus 
(Bang) is pathogenic for human be¬ 
ings is not proven, although it is pos¬ 
sible to cause antibodies for Bacillus 
abortus to appear in the blood-serum 
of adults by feeding a milk which is 
naturally infected with Bacillus abor¬ 
tus and which contains the Bacillus 
abortus antibodies. Cooledge (Jour. 
Med. Research, July, 1916). 

The writer found that complement 
fixation reactions with the polyvalent 
antigens *of bacillus abortus (Bang) 
and bacillus abortivo-equinus and the 
sera of 50 women aborting in the 
early months of pregnancy yielded 
negative results. Williams and Kol- 
mer (Am. Jour, of Obstet., vol. Ixxv, 
p. 194, 1917). 

A bacillus has been incriminated by 
Bang as a cause of abortion, but it is 
not receiving much support. 

Conversely, conditions which tend 
to exaggerate the contractility of the 
uterine muscle are also recognized 
causes. Ergot, copper sulphate and 
other “abortifacients” are familiar 
agents of this class. This evil action 
has also been attributed to quinine, 
but there is reason to believe that this 
valuable remedy should not be with¬ 
held in pregnant women, when in¬ 
dicated therapeutically, especially in 
view of the fact that malaria itself 


tends to cause abortion. Thus, in a 
study of the action of quinine on 
pregnant women, Frederici found that 
in 49 pregnancies quinine had been 
used in 47, the patients suffering more 
or less severely from malarial fever; 
47 terminated at the usual period by 
the birth of a child, and 2 aborted. 
In these 2 cases he deems it extremely 
probable that the high fever from 
which they suffered was instrumental 
in producing abortion. He concluded 
that medicinal doses of quinine were 
powerless to induce abortion. 

The writer collected 14 cases of 
severe poisoning from nitrobenzole 
used as abortifacient. The earliest, 
which occurred in 1866, was in a girl 
of 18 who, when 5 months pregnant, 
took 10 grains of the drug. Preg¬ 
nancy was not interrupted but the 
girl was severely poisoned with cya¬ 
nosis as a prominent symptom. The 
cases showed that nitrobenzole is 
without any abortifacient properties 
and can destroy fetal life only when 
the mother is fatally poisoned. Spin¬ 
ner (Corresp. Blatt. f. schweizer 
Aerzte, Oct. 27, 1917). 

Infectious diseases provoke abor¬ 
tion in a large proportion of cases 
when the febrile period is reached. It 
occurs in about two-thirds of preg¬ 
nant women attacked by typhoid 
fever, especially during the earlier 
months. Uterine hemorrhage is usu¬ 
ally the first symptom observed. Thus 
Sacquin collected 310 cases, and found 
abortion in 199; while Martinet found 
66 abortions in 109 cases. 

Small-pox causes abortion in about 
40 per cent, of the pregnant women it 
attacks and the mortality is about 50 
per cent., but is nearly 100 per cent, 
in the confluent type. In varioloid 
the child sometimes remains unaf¬ 
fected. The disease may also develop 
during convalescence. Abortion dur- 


ABORTION (WRIGHT). 


163 


ing variola is apt to be attended with 
more than the ordinary hemorrhage. 

Arnaud has reported several serious 
cases occurring during convalescence 
after small-pox. The grave symp¬ 
toms are attributed to the retention 
of the fetus, which died during the 
acute stage of small-pox, and was fre¬ 
quently only expelled during or after 
convalescence. 

Measles is an infrequent complica¬ 
tion of pregnancy, but, as observed 
by Klotz, it causes abortion in the 
majority of such instances. Pneu¬ 
monia frequently appears as an addi¬ 
tional complication. Scarlatina is 
also infrequently observed in preg¬ 
nant women, though it occurs com¬ 
monly as a complication of the par¬ 
turient state. 

Pneumonia causes abortion in about 
one-third of the pregnant women it 
attacks early and in two-thirds of 
those which contract the disease late. 
In the latter cases the fetus, though 
viable when bom, may soon die of 
the infection after birth. The sta¬ 
tistics of 213 cases of pneumonia 
during pregnancy published by Flatte 
showed that the pregnancy was inter¬ 
rupted in 118 cases, there being 42 
abortions and 76 premature deliveries. 
Death of the mother occurred in 75 
cases among the 213: a mortality of 
35 per cent. The mortality of the 
mother was greater in premature de¬ 
liveries than in abortion. 

Pulmonary tuberculosis, owing to 
its exhausting influence upon the nu¬ 
tritional resources of the body, renders 
it unfit to carry the fetus to term when 
the morbid process is far advanced. 
Abortion is relatively frequent in such 
cases, its occurrence and the viability 
of the child depending upon the stage 
of the disease. 


In 385 cases in which others ad¬ 
vised interruption of pregnancy the 
writer was able to escape it in 278 
instances. 

Only when cough, nightsweats, 
evening fever, and loss of weight 
continue in spite of sanatorium treat¬ 
ment is abortion indicated. 

After the first 3 months, he inter¬ 
venes only if the lung process is mild 
or only recently flaring up; otherwise 
one cannot hope to influence the 
disease. 

If patient has several living chil¬ 
dren, or if there is laryngeal tubercu¬ 
losis, or this is the first pregnancy 
in far advanced tuberculosis, he in¬ 
terrupts pregnancy and sterilizes the 
woman. With acute heart disease 
during a pregnancy he advises that 
the uterus be emptied by anterior 
colpohysterotomy under lumbar an¬ 
esthesia after the acute manifestations 
have subsided. Von Jaschke (Monats. 
f. Geb. u. Gynak,, Apr., 1920). 

Chorea, though a rare complication 
of pregnancy, causes abortion in one- 
half of the cases, and is especially 
observed in primiparae. If the de¬ 
livery occurs sufficiently late, the child 
may live, but is frequently aflected 
with chorea. The chorea sometimes 
ceases after delivery. 

Cardiac diseases influence preg¬ 
nancy when it is sufficiently marked 
to impair the general circulation. 
Acute pericarditis practically has no 
morbid influence on gestation, but 
chronic pericarditis is deemed per¬ 
nicious. Acute endocarditis assumes 
increased virulence during pregnancy, 
its tendency being to become ulcera¬ 
tive, and to entail a fatal ending. 

Icterus, in its various forms, some¬ 
times complicates pregnancy. Even 
simple catarrhal icterus may cause 
abortion, but in icterus gravis it 
occurs always and usually proves 
fatal. In the epidemic icterus of preg¬ 
nancy, the probability that abortion 


164 


ABORTION (WRIGHT). 


will occur is somewhat smaller, while 
the mortality is not as great. Preg¬ 
nancy not only aggravates even sim¬ 
ple icterus, but it increases the tend¬ 
ency to yellow atrophy of the liver. 

Paternal and Fetal Causes.—The 
influence of syphilis on abortion has 
been reviewed; in most instances it is 
acquired from the male directly, either 
before or after conception, the disease 
being communicated to the fetus, in 
the latter case, through the placenta. 
In accord with Colles’s law, the fetus 
may, as is well known, inherit the 
paternal syphilis, while the mother re¬ 
mains immune. Abortion may thus 
be caused through maternal or fetal 
syphilis acquired from the father. 

Any condition such as senility, al¬ 
coholism, overwork, etc., which tends 
to lower the vitality of the father tends 
also to weaken the oflfspring and pro¬ 
mote the tendency to miscarriage in 
the mother. Certain occupations 
which expose the patient to the action 
of certain poisons, mercury, phos¬ 
phorus, or lead, for instance, tend in 
the same direction. 

Besides the features which tend to 
compromise the development of the 
fetus that have been referred to, it is 
itself subject to injuries communi¬ 
cated from the exterior, blows, shocks, 
penetrating wounds (knife, bullets, 
etc.), etc. The application of X-rays 
has recently been added to the list of 
known causes. 

Low or vicious attachment of the 
placenta, degeneration of the chronic 
villosities, hydramnios are the remain¬ 
ing main abnormalities which affect 
directly the fetus and cause its pre¬ 
mature elimination by the uterus. 

PROGNOSIS.—Considerable loss 
of blood may occur in a case of 
threatened abortion, and yet the pa¬ 


tient, when properly treated, proceeds 
to full term. Cases of spontaneous 
abortion unattended by complications 
practically always recover. The de¬ 
gree of antisepsis has much to do 
with the result however; while, for 
example, in Pinard’s service where 
rigorous asepsis was observed the 
mortality was only 0.81 per cent.; cor¬ 
responding cases (which included fa¬ 
vorable and unfavorable) outside his 
services reached 27.5 per cent. Out 
of 610 cases treated at the Boston City 
Hospital in 10 years; 29 deaths, or 
4.75 per cent. They included a large 
proportion of induced and neglected 
cases. The deaths include cases with 
pre-existing typhoid and pneumonia. 
With two exceptions those of the 29 
deaths obviously due to the miscar¬ 
riage were caused by septic pneu¬ 
monia following a miscarriage be¬ 
tween 4 and 6 months. 

TREATMENT.—Treatment of 
Threatened Abortion.—When the 
symptoms of threatened abortion ap¬ 
pear we should endeavor to stop the 
morbid process, especially when the 
hemorrhage is not copious, the pains 
are not severe, and there is no evi¬ 
dence of the' escape of liquor amnii. 
Our chief aim should be to keep the 
patient absolutely quiet, by ordering 
her to bed, and relieve the pains due 
to uterine contractions by means of 
opiates in suitable doses. Opium 
seems to be better than morphine, even 
when the latter is given hypoder¬ 
mically. The tincture of opium, 30 
minims (2 Cm.) should be given by 
the mouth, followed by 15 minims 
(1 Gm.) every hour, repeated three or 
four times if required. Or, better 
still, 2 grs. (0.13 Gm.) of the aqueous 
extract of opium can be given as a 
rectal suppository, and 1 gr. (0.065 


ABORTION (WRIGHT). 


165 


Gm.) every hour afterward, three or 
four times if needed. If morphine be 
preferred, Yi gr. (0.032 Gm.) may be 
given hypodermically, and 
(0.016 Gm.) every hour, therefore, 
for three or four doses if required. 
An excellent plan when one wishes 
speedy effect from the opiate is to 
give at once Yz gr. (0.032 Gm.) mor¬ 
phine hypodermically, and 15 minims 
(0.92 Gm.) of tincture of opium by the 
mouth every hour afterward, or 1 gr. 
(0.065 Gm.) of extract of opium in a 
suppository every hour afterward for 
three or four doses if required. 

[Some physicians will consider that such 
dosage is large. Many physicians and ob¬ 
stetricians grew timid about the use of 
opium because of the violent antiopium 
riots that broke out in many surgical 
camps about twenty years ago, after Law- 
son Tait told the abdominal surgeons of 
the world that opium was an abomination 
which must be discarded in their work 
forevermore. The pendulum has turned, 
however, and is going the other way. A. 
H. Wright.] 

We ought, of course, to consider 
that opium should be given with 
great care. At the same time, the 
writer thinks it absurd to give, for 
instance, 10 minims (0.61 Gm.) of 
tincture of opium by the mouth, three 
times a day, for the pains of threatened 
abortion. As a rule such doses will 
have no good effect, because they will 
not relieve the pains, and they may 
have a bad effect by causing constipa¬ 
tion. Opium does cause constipation, 
and thus interferes with elimination, 
but the writer does not admit that it 
causes complete ^paresis of the intes¬ 
tines. Sepsis alone causes that kind 
of paresis. 

The constipation caused by opium 
can be easily overcome by the admin¬ 
istration of ordinary laxatives. If, 


however, the physician who has given 
opium in the case of threatened abor¬ 
tion is afraid to use mild cathartics 
for constipation, he might order an 
ordinary enema. 

Some years ago the administration 
of viburnum prunifolium was sup¬ 
posed to have a good effect in cases of 
threatened abortion. The result of 
recent experience does not indicate 
that such supposition is correct. The 
writer considers it practically worth¬ 
less. The fluidextract, to 1 dram 
every three hours, or 10 drops every 
hour, with chloral hydrate 8 grains, 
have, however, been found effective 
in arresting uterine contractions when 
opium could not be used or when 
its constipating effects might prove 
detrimental. Or, chloral hydrate, 10 
grains, and potassium bromide, 20 
grains every two or three hours, may 
be preferable, since the hypnotic tends 
to insure the absolute rest and quiet 
that should be observed to obtain a sat¬ 
isfactory result. Codeine is preferred 
to other opiates by some obstetricians. 

Treatment of Inevitable Abortion. 
—There never has been, and probably 
never will be, a consensus of opinion 
among obstetricians as to the treat¬ 
ment of abortion. It seems conven¬ 
ient to consider that there are three 
general plans: expectant treatment, 
treatment by tamponade, forced dila¬ 
tation of the cervix and curettement. 

Expectant Plan.—The term expect¬ 
ant is not a good one as a rule, and it 
becomes most unsuitable if it is mis¬ 
understood. 

Lusk was perhaps the most prom¬ 
inent advocate of the expectant plan 
of treatment. He urged that, when in 
the third month the ovum is thrown 
off without the rupture of the mem¬ 
branes, the hemorrhage rarely as- 


166 


ABORTION (WRIGHT). 


sumes dangerous proportions, and 
explained how the uterine contrac¬ 
tions sometimes pressed the ovum 
into the cervix. During these uterine 
contractions the ovum descends and 
the upper portion of the body of the 
uterus retracts. Some coagulation of 
the blood takes place between the 
ovum and the retracted uterine walls, 
while the ovum forms a tampon 
which fills the cervix like a ball valve, 
and thus restrains the hemorrhage. 
When there is no interference, the 



Ovum, five weeks. 


ovum, after being retained for a time 
as described, is frequently expelled 
entire, leaving the uterus in the best 
possible condition for satisfactory in¬ 
volution. In such cases, and they are 
by no means uncommon, nature has 
done well. Why should we try to 
improve or interfere with such mag¬ 
nificent work? 

Opinions still differ greatly as to 
whether active or conservative meas¬ 
ures are preferable, but at the Strass- 
burg clinic, in charge of Fehling, 
active treatment is the usual course. 
A very important guide for the man¬ 
agement of the case is what she calls 
“latent complications,” namely, that 


while nothing pathologic can be pal¬ 
pated, yet the patients complain of 
pains during internal examination. 
Tenderness of the vaginal portion of 
the uterus or tissues around indicates 
incipient inflammation, showing that 
the morbid process is not restricted 
to the endometrium but is extending 
beyond it. This calls for strict con¬ 
servative treatment, just as much as 
exudation in the pouch of Douglas or 
disease of tube or ovary. B. Engler 
(Corresp. Blatt f. schweizer Aerzte, 
July 21, 1917). 

Removal of the Uterine Contents. 

—It should be definitely understood 
that, while nature is doing good work, 
we should watch carefully, and be ready 
to assist when her efforts have ceased 
to be efficacious. When the os and 
cervical canal are sufficiently dilated 
to allow the introduction of the finger 
into the uterine cavity, and the uterine 
contents are not extruded, we should 
interfere, and endeavor to empty the 
uterus. We should presume, unless 
there is positive proof to the contrary, 
that the ovum is intact, and should 
not be broken. 

The following course is recom¬ 
mended : Place the patient across the 
bed, in the lithotomy position, and 
with the external hand endeavor to 
depress the uterus through the ab¬ 
dominal wall until the index finger of 
the other hand (carefully asepticized) 
can be passed through the os and up 
to the fundus. An anesthetic is only 
occasionally required. Pass the fin¬ 
ger up on the lateral wall of the 
uterus until it is above the ovum, at 
or near the opening of one of the 
Fallopian tubes; then pass it across 
the fundus to the neighborhood of the 
other Fallopian tube, and sweep down 
this wall, driving the contents of the 
uterus before it. In these manipu¬ 
lations try to avoid rupturing the 



ABORTION (WRIGHT). 


167 


ovum. If unable to remove the ute¬ 
rine contents in the way described, one 
should try the following Rotunda 
procedure: Take the finger out of the 
uterus and place it under the fundus, 
that is to say, in the anterior fornix if 
the uterus is normal in position, and 
in the posterior fornix if the uterus is 
retroverted. Sink the other hand 
into the abdomen and compress the 
body between the two hands. The 
ovum is then driven out of the uterus 
into the vagina and removed (Jellett). 

It is well to remember that there is 
a period between early and late abor¬ 
tion—say, in the latter part of the 
third month—when it is difficult, 
with the finger-tip, to make out 
the placenta, because it feels exactly 
like the endometrium. It is possible 
under such circumstances to make 
the mistake of imagining that the 
uterus is empty while the thin, 
broad placenta is completely ad¬ 
herent. In such a case it is better 
to try to remove this placenta by 
scraping with the finger-tip, as the 
use of the metallic curette under such 
circumstances is dangerous. 

Analysis of 750 cases of abortion of 
the out-patient department of the 
Chicago Lying-in Hospital, and 
treated at their homes. The routine 
treatment adopted in the 276 cases of 
threatened hemorrhage was absolute 
rest in bed, with morphine and 
codeine every four hours, with saline 
purgatives where needed. When 
malposition of the uterus was pres¬ 
ent, this defect was corrected. The 
pregnancy was saved in 72.8 per 
cent, of the cases. The inevitable 
abortions were treated by packing 
and curetting with the finger when 
possible, using the curette only when 
absolutely necessary, excepting in 
chronic cases. All the mothers re¬ 
covered. 

Summary of conclusions: Absolute 


rest was imperative; blood loss should 
always be prevented: cotton pledgets 
are preferable for tampons to gauze, 
being firmer; whenever possible emp¬ 
tying of the uterus should be done 
with the finger; laminaria tents are 
difficult to sterilize. Stowe (Surg., 
Gynec. and Obstet., Jan., 1910). 

Divergent views continue to exist 
regarding the relative advantages of 
active and conservative treatment in 
non-septic abortion. According to 
the writer, curettage is necessary in 
40 per cent, of non-septic cases 
treated expectantly. 

The curettage insures an empty 
uterus, prevents subsequent bleeding, 
shortens the patient’s stay in the hos¬ 
pital, and is relatively harmless. D. 
S. Hillis (Surg., Gynec. and Obstet., 
xxxi, 605, 1920). 

The Tampon.—The vaginal tampon 
(or plug, as it is still termed by many 
in Great Britain) has been used for 
various obstetrical purposes for cen¬ 
turies. We believe that treatment by 
tamponade is the safest and best kind 
in all varieties of inevitable abortion, 
whether complete or incomplete. 

There are two kinds of tamponade: 
the vaginal and uterovaginal. 

Vaginal Tamponade .—In order to be 
efficient the vaginal tamponade should 
be properly done. Although it is one 
of the simplest of obstetrical opera¬ 
tions it appears that in the majority 
of cases it is imperfectly carried out. 
In the first place the vagina cannot 
be properly plugged while the patient 
is lying on her back, or on her side. 
The patient must be put in the Sims 
(semiprone) position. The perineum 
and pelvic floor must be thoroughly 
retracted by a Sims speculum, and 
the vagina properly ballooned, so that 
its vault, thus distended, may be com¬ 
pletely filled by the material used for 
the packing. It is only necessary to 
pack tightly the upper two-thirds or 


168 


ABORTION (WRIGHT). 


three-fourths of the vagina. The 
mistake commonly made of packing 
tightly the entrance of the vagina 
generally causes great pain, and fre¬ 
quently retention of urine, by pres¬ 
sure on the urethra. 

The tampon checks the hemorrhage, 
dilates the cervix, assists further sep¬ 
aration of the ovum by damming back 
the blood, and induces uterine con¬ 
tractions. The writer, like Smellie, 
prefers an antiseptic plug, and uses 



material impregnated with 5 per cent, 
iodoform. A simple sterile plug is 
introduced by some, but an antiseptic 
plug is better. The former becomes 
foul in about twelve hours, while the 
latter (when iodoform is used) re¬ 
mains sweet for two or three days. 
The ordinary iodoform gauze is not 
suitable however, because it is too 
coarse in texture, that is, too much like 
a sieve. The blood easily runs through 
it. Therefore, the writer prefers to 
use a rather fine cheesecloth impreg¬ 
nated with the iodoform. 

[It is prepared for me by Miss Margaret 
Lash, as follows: Take 4 yards of cheese¬ 
cloth (good quality) 27 inches wide; tear 


(not cut) into strips 4^2 inches wide and 
full length; sterilize these strips, and then 
boil in sterile water; wring them as dry as 
possible (having hands covered by sterile 
gloves) and thoroughly saturate them in the 
following preparation: 8 ounces of a 1 per 
cent, solution of carbolic acid in sterilized 
water, and enough Castile soap to make 
suds; 3 drams and 1 scruple of iodoform 
powder; mix thoroughly in sterile basin 
with sterilized pestle or glass rod. After 
thoroughly saturating the strips, wring as 
dry as possible, and pack the gauze strips 
one after another into sterilized glass jars, 
and seal down while moist. One strip 4>4 
inches wide by 4 yards long is ample for 
most vaginal tampons. This happens to 
be one-half of a square yard, that is, 3 feet 
by one foot and a half. A. H. Wright.] 

The method of procedure for early 
abortion is as follows: Place the pa¬ 
tient in the Sims position, introduce 
a Sims speculum, and let the assistant 
retract the perineum and pelvic floor 
(or use two fingers of one hand for 
such retraction, as recommended by 
Schauta) ; introduce the continuous 
strip of iodoformed cheesecloth, and 
firmly pack the vault of the vagina. 
In doing this one should use not the 
point of a sound or forceps with fine 
points, but something with a fairly 
large surface. My custom is to use 
the handle of a uterine sound when 
packing tightly. Continue the pack¬ 
ing until the upper three-quarters of 
the vagina is filled, and then allow the 
end of the strip to hang out at the 
vulva. If in a few hours strong pains 
occur, indicating that regular uterine 
contractions are taking place, take 
hold of the end of the strip and pull 
out the material forming the plug. 
It may be that by this time the ovum 
has been separated and expelled from 
the uterus. If such pains do not 
occur remove the tampon in twenty- 
four hours. There will then probably 
be some slight dilatation of the os. 











ABORTION (WRIGHT). 


169 


but not enough perhaps to allow the 
introduction of the finger. Introduce 
a second tampon as before. The tam¬ 
ponade may be kept up with safety 
for many days (a week or more) if the 
plug is renewed every twenty-four 
hours. It is unnecessary for the first 
two or three days to introduce any of 
the iodoformed strip inside the uterus, 
because the aim is to cause uterine 
contractions that will expel the entire 
ovum. 

If it is found, after the removal of 
the second or third tampon, that the 
os and cervical canal are sufficiently 
dilated to allow the introduction of 
the finger, we may explore the interior 
of the uterus, as recommended in con¬ 
nection with the expectant plan, and 
endeavor to remove the complete 
ovum. If, however, a portion of the 
ovum has come away, the uterovagi¬ 
nal tamponade becomes the proper 
procedure. 

It may be well now to repeat that 
the object of the vaginal tamponade 
is to cause the expulsion of the en¬ 
tire ovum during early abortion, that 
is, before the complete placenta is 
formed. The object of the utero¬ 
vaginal tamponade is' to empty the 
uterus in case of incomplete abortion 
(whether early or late), and also in 
case of late abortion, that is, after the 
complete placenta has been formed. 

Uterovaginal Tamponade .—This pro¬ 
cedure is divided into two stages: 1, 
the packing of the uterus; 2, the pack¬ 
ing of the vagina. In packing the 
uterus it is generally more convenient 
to place the patient on her back in the 
lithotomy position, on a couch, on a 
table, or across the bed. Introduce a 
weight speculum, seize the anterior 
lip of the uterus with a volsellum 
forceps, and use slight traction. Or¬ 


dinary iodoform gauze one-half to 
one inch wide is now pushed as far 
up as possible into the uterine cavity, 
employing a fine curved pair of uter¬ 
ine forceps, a uterine gauze packer, 
or a uterine sound to do so. 

In order to carry out the second 
stage of the operation the patient is 
placed in the Sims position, and the 
end of the narrow strip, the greater 
portion of which has been passed 
into the uterus, is tied to the wider 
strip used for the vaginal tamponade. 
After retracting the perineum and 
pelvic floor, the upper three-fourths 
of the vagina is packed tightly in the 
manner previously described. 

If strong uterine contractions occur 
the double plug and ovum may be 
expelled together. If no strong ute¬ 
rine contractions commence withdraw 
tampon in twenty-four hours, and in¬ 
troduce a new one. This procedure 
means, of course, that the membranes 
will be punctured, if they were not 
previously ruptured. This is suitable 
for all cases of abortion between the 
end of the third and the end of the 
seventh month. In the seventh month 
we must consider the possibility of 
the expulsion of a living child. In 
helping deliver}^ during this month, 
and sometimes in the fifth or sixth 
month, one may introduce a gum elas¬ 
tic bougie (English No. 12) within 
the uterus or a medium-sized rectal 
tube (H. U. Little), as recommended 
by Krause, and follow with the 
vaginal tamponade. However, the in¬ 
troduction of the gauze through the 
cervical canal and into the lower 
uterine segment, with the vaginal tam¬ 
ponade, is generally quite sufficient to 
produce efficient uterine contractions. 

The treatment of abortion is consid¬ 
ered by the writer under three heads: 


170 


ABORTION (WRIGHT). 


(1) imminent abortion may be pre¬ 
vented by absolute rest in bed and the 
use of drugs like codeine and vibur¬ 
num prunifolium; (2) progressing 
abortion, and (3) incomplete abortion 
may be assisted to a spontaneous ter¬ 
mination by a hot vaginal antiseptic 
douche and vaginal gauze packing. 
An oxytocic should be administered in¬ 
ternally. If the result is not satisfactory 
after twenty-four hours, the partially 
dilated cervical canal should be packed 
with gauze and the vagina below tightly 


controls the bleeding, but aids in the 
expulsion of the placenta. He believes 
that the method is safe and efficacious, 
and prompt in its influence. Two to 
three drops of adrenalin solution mixed 
with 1 c.c. of physiological salt solu¬ 
tion is injected. Of course, careful 
asepsis must be maintained. In giving 
the injection it is best to use a Sims 
speculum. If results are not prompt, 
the injection may be repeated in a few 
minutes. Crasser (Centralbl. f. Gynak,, 
Nu. 25, 1909). 


Outline of Treatment in Abortion and Miscarriage. 



First Six Weeks op Preg¬ 
nancy. 

Seventh to the Thirteenth 
Week. 

Fourth to the Sixth 
Month. 

Cervix closed. 

Cervix open. 

Cervix closed. 

Cervix open. 

Cervix closed. 

Cervix open. 

Ovum re¬ 
tained. 

Cervical and 
vaginal tam¬ 
ponade. 

Removal with 
one finger. 

Cervical and 
vaginal tam¬ 
ponade. 

Removal with 
one finger. 

Tamponade or 
dilate with 
small Voor- 
hees bag. 

Removal with 
two fingers. 

Ovisac or 
placenta 
retained. 

Uterine tam¬ 
ponade. 

Removal with 
ovum for¬ 
ceps under 
guidance of 
finger. 

Uterine tam¬ 
ponade. 

Removal with 
one finger. 

Tamponade or 
dilate with 
finger. 

Removal with 
one or two 
fingers. 

Placental 
pieces or 
decidua 
retained. 

Dull curette. 

Dull curette. 

Dull curette. 

Dull curette 
under guid¬ 
ance of 
finger. 

Curette care¬ 
fully or di¬ 
late to admit 
finger. 

Removal with 
one finger. 


F. J. Taussigr (Surgf., Gynec., and Obstet., May. 1909). 


filled with the same material. Uterine 
contraction will thus be usually incited 
and everything expelled. If too much 
bleeding is going on, the uterus may be 
emptied with the finger or placenta 
forceps, and ergot administered, two or 
three doses usually sufficing. H. J. 
Boldt (Jour. Amer. Med. Assoc., Mar. 
17, 1906). 

Table containing the kernel of the 
operative indications. If conscien¬ 
tiously followed, it will, the writer 
believes, lead to considerable improve¬ 
ment in the practitioner’s treatment of 
abortion and miscarriage. 

For several years the writer has been 
in the habit of injecting adrenalin into 
the uterine cervix in cases in which 
there was bleeding after abortion with 
retention of the placenta. It not only 


Conclusions based on the results in 
2000 cases of-miscarriage : 1. Spontane¬ 
ous emptying of the uterus takes place 
in but about 13.2 per cent, of all miscar¬ 
riages. 2. The likelihood of a miscar¬ 
riage to complete itself increases with 
the duration of pregnancy. 3. When it 
becomes necessary to use artificial 
means to complete the miscarriage, the 
finger followed by the curette in later 
miscarriages, and the curette alone 
in the earlier months of pregnancy, has 
given uniformly satisfactory results. 4. 
Experience has shown that where the 
cervix is extremely rigid it is better to 
introduce the curette and break up the 
fetus and placenta and remove them 
piecemeal than to attempt to dilate the 
cervix sufficiently to introduce the fin¬ 
ger. S. Packing the vagina and lower 





































ABORTION (WRIGHT). 


171 


segment of the uterus is an unsatisfac¬ 
tory and often unsuccessful method of 
emptying the uterus. No success what¬ 
ever was obtained in treating incom¬ 
plete miscarriages in this way. 6. Pack' 
ing is, however, of great value in two 
classes of cases: First, in exsanguin¬ 
ated patients to stop the hemorrhage 
and give the woman a chance to re¬ 
cover somewhat from the loss of 
blood before emptying the uterus. 
Second, when the cervix is very 
rigid, a tight cervical pack for 
twenty-four hours will soften it so 
that dilatation may be attempted with 
safety. 7. The results of artificial 
methods are as good as, but not 
better than, where nature has suc¬ 
ceeded in emptying the uterus. 8. 
Artificial methods are necessary in a 
majority of cases, however, simply 
because nature has failed. 9. In in¬ 
fected cases the essential thing is to 
empty the uterus. 10. The later in 
pregnancy miscarriage occurs, the 
smaller the liability to become' in¬ 
fected, but the greater the likelihood 
of developing grave septic complica¬ 
tions if infection occurs. E. B. Young 
and J. T. Williams (Boston Med. 
and Surg. Jour., June 22, 1911). 

In cases of hemorrhagic abortion 
the author has the uterine secretion 
examined at once, and if streptococci 
are found, the uterus is not evacu¬ 
ated but conservative treatment pur¬ 
sued. He does not believe the 
danger of fatal hemorrhage at an 
abortion sufficiently great to consti¬ 
tute a contraindication in the presence 
of a streptococcus infection. Neu 
(Miinch. med. Woch., Nov. 19, 1920). 
Treatment of Incomplete Abortion. 
—Some authors state that the uterus 
may be emptied at once, the cervical 
canal being dilated and the finger or 
curette or both being used. Occasion¬ 
ally the finger may be used with ad¬ 
vantage when the cervical canal is 
well dilated, but we do not advise the 
use of the curette. Others hold that 
we should not interfere until there is 
decomposition of the ovum or danger¬ 


ous hemorrhage. We do not approve 
of this kind of expectant treatment. 

Without discussing these or other 
methods of treatment we recommend 
the uterovaginal iodoform tamponade 
for all kinds of incomplete abortion, 
whether occurring before or after the 
formation of the placenta. In these 
cases there is nearly alvTays some 
dilatation of the cervical canal, gen¬ 
erally enough to allow the introduc¬ 
tion within the uterus of a narrow 
strip of iodoform gauze. If the canal 
which was once slightly dilated has 
again become so contracted that no 
gauze can be passed through it we 
may do the vaginal tamponade as be¬ 
fore directed, and thereby cause suffi¬ 
cient dilatation for our purposes. If 
we use the iodoform gauze or cheese¬ 
cloth instead of ordinary sterile gauze, 
we do not fear the danger of decom¬ 
position which is said by some to 
occur in the uterine cavity about the 
vaginal plug. If, however, one fears 
such an occurrence he should remove 
the vaginal plug in ten or twelve 
hours, instead of waiting twenty-four 
hours, as we have generally recom¬ 
mended. The uterovaginal tampon¬ 
ade may be repeated several days if 
considered necessary. 

If after waiting one or two weeks 
the accoucheur has reason to fear that 
some portions of the egg have been 
retained, and there are no signs of 
sepsis, he may use a dull curette with 
great care. 

In the Michael Reese Hospital from 
1912 to 1914, the treatment of incom¬ 
plete abortions consisted in tent dila¬ 
tion from 8 to 24 hours, digital empty¬ 
ing of the uterus when possible, 
otherwise curettage, followed by in- 
tra-uterine irrigation of Yz per cent, 
iodine. When the history and physi¬ 
cal findings were those of an incom¬ 
plete abortion, the uterus v:as emptied 


172 


ABORTION (WRIGHT). 


within 24 to 36 hours after the patient 
entered the hospital. This was done 
whether or not there was any tem¬ 
perature. Despite the cultural find¬ 
ings, which in 50 cases showed the 
usual number of anaerobic and aero¬ 
bic bacteria, the uterus was emptied 
in 24 to 36 hours. The value of this 
advice is indicated by the low mor¬ 
tality: .06 per cent, in 579 cases. 
J. E. Lackner (Surg., Gynec. and 
Obstet., XX, 537, 1915). 

The writer gives 1 c.c. (16 minims) 
of pituitary extract hypodermically 
before curetting for incomplete abor¬ 
tion and finds that it produces firm 
uterine contraction, which makes the 
curettement easier and almost blood¬ 
less. H. D. Furniss (Surg., Gynec. 
and Obstet., Sept., 1916). 

The seriousness of the retention of 
the ovular envelope or of placental 
structure has been considerably over¬ 
estimated in incomplete abortion. In¬ 
terference offers more risk of infec¬ 
tion than waiting. The average 
physician should content himself with 
vaginal tamponade for hemorrhage 
without any intra-uterine manipula¬ 
tion whatever. Removal of the tam¬ 
pon after 12 to 24 hours is usually 
followed by expulsion of the retained 
material, though exceptionally it may 
be necessary to repack the vagina. 
If the cervix is well dilated and the 
ovular mass is presenting at the cer¬ 
vix, the latter may be expressed by 
external compression of the uterine 
fundus or withdrawn by means of a 
wide-blade placental forceps. Intra¬ 
uterine irrigation is condemned, and 
the advisability of vaginal douching 
is questionable. It may be necessary 
later, however, to dilate, curette, and 
pack the uterus to remove a so-called 
placental polyp. J. M. Fisher (Therap. 
Gaz., xliii, 233, 1919). 

Sepsis with incomplete abortion is 
a very serious complication. The 
curette, whether dull or sharp, should 
never be used when there is septic 
endometritis or even saprophytic in¬ 
fection. The finger may be used very 


gently to remove debris when the 
cervical canal is sufficiently dilated. 
Then use an intrauterine douche of 
warm salt solution. After the douche 
is used introduce iodoform gauze (the 
coarser, the better) into the uterus, 
and place a certain amount in the 
vagina without packing tightly. Leave 
this in six hours, and then remove. 
After this removal keep the patient as 
much as possible in Fowler’s position, 
that is, a half-sitting position, to facili¬ 
tate drainage. Apart from such local 
treatment carry out the usual line of 
treatment recommended for puerperal 
infection. 

There is marked tendency among 
leading authorities toward conserva¬ 
tive treatment and limiting the use 
of the curette. The writer found 
that during the 5 years, inclusive 
from 1910 to 1914, there were treated, 
in the gynecologic wards at Jeffer¬ 
son Hospital, 296 patients, the great 
majority of whom suffered from in¬ 
fection, many being well advanced 
and practically hopeless. Many of 
them had undergone curettement 
prior to entering the hospital; 127 
or nearly 43 per cent., were subjected 
to some surgical procedure after ad¬ 
mission. Careful analysis of the 
cases convinced him that a smaller 
mortality would have occurred had 
these patients been received before 
they had been subjected to any surg¬ 
ical interference and the treatment 
confined to non-surgical measures. 
It should be remembered that, even 
admitting the retention of embryonic 
products, the infective organisms do 
not limit themselves to the local 
area. If they have not already in¬ 
vaded the blood, the manipulation 
necessary to explore and remove the 
retained tissue breaks down the bar¬ 
riers nature has erected against fur¬ 
ther invasion. Montgomery (Jour. 
Amer. Med. Assoc., Oct. 9, 1915). 

Curettage and Emptying the Uterus 
at a Single Sitting.— This operation 


ABORTION (WRIGHT). 


173 


may be occasionally justifiable when 
there appears to be urgent need 
of rapid emptying of the uterus. 
Whether this be true or not it is 
recognized as a legitimate operation 
by some of the best obstetricians and 
gynecologists in the world. A brief 
description of the procedure is there¬ 
fore given. Anesthetize the patient, 
place her in the lithotomy position 
“across bed,” preferably on a Kelly pad. 
Prepare external parts and vagina as 
for vaginal hysterectomy, using espe¬ 
cially green soap and hot water, and a 
hot solution of lysol or other germi¬ 
cide. Introduce a weight speculum, 
secure the anterior Up of the cervix 
with volsellum forceps, introduce a 
branched steel instrument into the 
cervical canal, and dilate; then intro¬ 
duce a curette into the interior of the 
uterus and scrape out its contents. 
Some operators then wash out the 
interior of the uterus with an antisep¬ 
tic solution, while others use the 
uterine iodoform tamponade. 

The advocates of the active treat¬ 
ment have not had as good results as 
those who use the expectant plan. 
While the latter gave a morbidity of 
9.8 per cent, and a mortality of 0.8 
per cent., the active treatment gave 
a morbidity of 29 per cent, and a 
mortality of 9.8 per cent. The mor¬ 
tality with hemolytic streptococci 
was 31.2 per cent, with active treat¬ 
ment and zero with conservative. 
The strictly conservative treatment 
is reserved for the cases showing 
hemolytic streptococci. W. Benthin 
(Monatsch. f. Geburtsh. u. Gynak., 
xlii, 162, 1915). 

The writer found that it was 
possible to empty the uterus in the 
early stages of pregnancy in a few 
minutes with the aid of pituitrin and 
a curette, with very little loss of 
blood and without shock or collapse 
even in the most severe cases. No 
hot irrigations were required to as¬ 


sist in the expulsion of the fetus or 
placenta, nor were any irrigations or 
packing employed after evacuation of 
the uterus. The injection of 1 c.c. 
(15 minims) of pituitrin was given 
after the cervix had been dilated, 
while the patient was under the an¬ 
esthetic. 

In some instances the curette was 
unnecessary, strong pains beginning 
within a few minutes and entirely ex¬ 
pelling the uterine contents. Where 
the uterus was unable to evacuate 
itself, the curette was used to sep¬ 
arate the adherent placenta from the 
uterine wall, a procedure which 
caused practically no bleeding, even 
if the placenta was removed piece¬ 
meal, owing to the firm, hard condi¬ 
tion of the uterine wall due to the 
drug. The uterine cavity was wiped 
dry with gauze and swabbed with 5 
per cent, iodine solution. It de¬ 
creased in size rapidly. J. L. Bubis 
(Amer. Jour, of Obstet., April, 1916). 

The writer recommends the follow¬ 
ing course in septic abortion: Ex¬ 
pectant treatment is followed until 
the abortion is completed spontane¬ 
ously. If severe or protracted slight 
hemorrhage makes interference un¬ 
avoidable, the uterus is packed. The 
packing is removed after 12 to 24 
hours and frequently the whole rem¬ 
nants of the abortion come away. H 
not, the packing has usually dilated 
the cervix sufficiently so that the 
uterus can be emptied manually. Re¬ 
peated packing is -not favored. If 
the uterus is not empty after the 
removal of the packing, it is emptied 
preferably by hand, if necessary after 
additional dilatation with Hegar’s di¬ 
lators and if the hand is insufficient, 
with the sharp curette. The longer 
the interval between the last rise of 
temperature and the operation the 
better. Packing afterward is avoided, 
unless necessitated by severe hemor¬ 
rhage. The uterus is never irrigated. 
Ergot is given only when hemorrhage 
exists after complete evacuation of 
the uterus. Vaginal douches are never 
given until at least a week after the 
abortion and then only for subinvolu- 


174 


ABORTION (WRIGHT). 


tion, not for purulent discharges. 
The patient is usually discharged 3 
days after the last rise of temperature. 
Ries (Surg., Gynec. and Obstet., Apr., 
1918). 

In febrile abortion the writer pre¬ 
fers merely to aid the natural forces 
in emptying the uterus. An ice bag 
is kept constantly on the abdomen to 
favor uterine contractions and 0.2 
Gm. (3 grains) of quinine given 
every 4 or 6 hours. In 40 to 50 per 
cent, of cases uterine contractions 
usually appear after the second dose 
of quinine and result in expulsion of 
the ovum and placenta. All lavage, 
irrigation, and douches are forbidden. 
The vulvar dressings are changed 3 
or 4 times daily. Cases in which 
abortion cannot be effected by this 
method are generally left alone for 
3 or 4 days, during which time the 
temperature usually returns to nor¬ 
mal. Curettage is then performed 
and is easier and less dangerous, as 
the uterine cavity is almost empty, 
the uterus small, and the uterine walls 
firmly contracted. A. Villar (Rev. 
argent, de obst. y ginec., iv, 10, 1920). 

Treatment of Criminal Abortion._ 

In the majority of cases of criminal 
abortion we have incomplete abor¬ 
tion with sepsis. We have to con¬ 
sider at the same time that some 
injury may have been done by the 
operator in his manipulations. One 
of the most common of such injuries 
is puncture of the uterine wall. The 
possibility of such injury should make 
us doubly careful in our methods of 
treatment. 

Treatment of Patient with “Abort¬ 
ing Habit.”—When we have treated 
a certain patient for two or three 
threatened abortions which have be¬ 
come inevitable, the presence of syph¬ 
ilis should be carefully inquired into. 
If there is a syphilitic taint, or even a 
suspicion of it, both patient and hus¬ 
band should be placed under constitu¬ 
tional treatment. Malformations, dis¬ 


placements and other abnormalities 
of the uterus, and other conditions 
which act as direct causes of abortion 
may, of course, prevail in these cases, 
and should be carefully sought after. 

Apart from such considerations, 
rest and quiet are the important ele¬ 
ments in the treatment of such cases. 
The patient should be kept in bed or 
on a lounge from two days before the 
time of menstruation until three days 
after it ceases. In addition, if the 
patient is restless or sleepless, she 
should receive enough opium or other 
hypnotic, such as veronal, to make her 
sleep at least fairly well every night. 
During intervals she should have a 
moderate amount of exercise in the 
open air, and suitable tonics. Strong 
purgatives, vaginal douching, sports, 
and all kinds of fatiguing work should 
be carefully avoided. In case of re¬ 
troversion or retroflexion, the dis¬ 
placement should be corrected, in¬ 
troducing, if necessary, a suitable 
pessary, and leaving it until about the 
end of the fourth month. 

The automobile, particularly when used 
over rough roads is not infrequently a 
cause of abortion, especially when the 
fetus is sufficiently large to contribute a 
mechanical factor and weight to the mor¬ 
bid process. Horseback riding likewise 
increases the danger. Editors. 

ABERRANT FORMS.—The rec¬ 
ognition of such conditions obviously 
is of great diagnostic importance. 

Missed Abortion.—The retention of 
the ovum within the uterus after its 
death is thus termed. The death of 
the ovum may occur before or after 
the formation of the placenta, but it 
is most apt to happen in the third 
month. This is probably due to the 
fact that at that time the egg is to 
some extent loosened on account of 
the atrophy of a large portion of the 


ABORTION (WRIGHT) 


175 


chorionic villi. The death of the fe¬ 
tus frequently occurs, however, in the 
fourth, fifth, sixth or seventh month, 
and in a certain proportion of these 
cases the abortions are “missed.” 

It is a singular fact, in connection 
with a case of missed abortion, that 
the dead ovum frequently or generally 
remains in the uterus quiescent until 
term. In some cases the dead ovum 
still remains quiescent for an indefi¬ 
nite time, even after term. Although 
we cannot speak very definitely, we 
know that the dead ovum may remain 
in the uterus without any change in 
structure for one, two or more years. 
At least such appears to be the opinion 
of the majority of obstetricians at the 
present time. 

[This fact is sometimes of great impor¬ 
tance from a medicolegal standpoint. The 
case of Kitson vs. Playfair, which was 
tried in England about fourteen years ago, 
created intense interest. Dr. Playfair, the 
distinguished teacher and writer on ob¬ 
stetrics and gynecology, while treating in 
an ordinary professional way Mrs Kitson, 
the wife of Mrs. Playfair’s brother, emp¬ 
tied the uterus, and found something like 
fresh placenta. Examination under the 
microscope confirmed his suspicion, and he 
expressed the opinion that there had been 
a recent incomplete abortion. As Mrs. 
Kitson had not seen her husband for over 
a year (he being in India and she in Eng¬ 
land) this meant a charge of immorality. 
Dr. Playfair informed his wife, and Mrs. 
Kitson was dismissed in disgrace from her 
ordinary circle of relatives and acquaint¬ 
ances. The husband in consequence en¬ 
tered action against Dr. Playfair. It cost 
the latter altogether over $50,000. Many 
thought also that he was not justified in 
revealing a professional secret. A. H. 
Wright.] 

Mole.—When the dead ovum or a 
portion of it is retained in the uterus 
it is called by many a mole. When 
there has been extravasation of blood 


between the layers of the membranes 
or into the substance of the decidua, 
coagulation takes place and the mass 
with its clot or clots is called a “blood 
mole.” When there has been repeated 
extravasation of blood within the 
ovum the blood-strata undergo partial 
organization and the mass is called a 
“flesh mole.” This flesh mole retains 
to some extent its attachment to the 
uterine wall, and in some cases after 
partial detachment may form new at¬ 
tachments. Under such circumstances 
the detention of the mass within the 
uterus may be much prolonged, as 
before mentioned. 

Treatment of Uterine Flesh Mole .— 
There is far from a consensus of 
opinion as to the treatment of such a 
mole. Some say leave it alone if 
there are not disturbing symptoms; 
others say empty the uterus at once 
when a diagnosis is made. It hap¬ 
pens that a diagnosis is frequently 
difficult or impossible, and it also hap¬ 
pens that in the majority of cases the 
mole is expelled from the uterus with¬ 
in a reasonable time. The general 
practitioner will be on the safe side 
not to interfere unless serious symp¬ 
toms arise. If very serious symptoms 
do appear he should at once do 
the uterovaginal tamponade as before 
recommended. 

Hydatiform Mole (syncytioma be- 
nignum, vesicular mole, myxoma 
chorii).—This is a vesicular tumor 
within the uterus formed by sim¬ 
ple hyperplasia or cystic degeneration 
of the villi of the chorion at any 
time during pregnancy, but most fre¬ 
quently in the early months, and often 
after abortion. 

The accoucheur, in considering the 
symptoms of a supposed abortion, 


176 


ABORTION (WRIGHT). 


should ever keep in view hydatiform 
mole and chorion epithelioma, because 
early diagnosis and prompt treatment 
of both neoplasms are so extremely im¬ 
portant. The first symptom of the 
former is a discharge of a bloody fluid 
which is sometimes said to resemble 
currant juice. Our first suspicion is 
generally threatened abortion. If the 
discharge becomes more watery in ap¬ 
pearance, if vesicles are expelled, or 
if the uterus increases abnormally in 
size, we should suspect a vesicular 
mole. Generally we have to be guided 
by two symptoms, hemorrhage, and ab¬ 
normal increase in the size of the 
uterus. 

Treatment of Hydatiform Mole .— 
T he condition is serious and prompt 
treatment is required. The uterus 
should be emptied as soon as pos¬ 
sible. The following is recommended: 
Dilate the cervical canal with Hegar’s 
dilators, then introduce a sea-tangled 
tent, then plug the vagina as before 
described. If strong uterine contrac¬ 
tions come on within a short time re¬ 
move the tampon and tent. If such 
contractions do not come on remove 
the tampon and tent in twenty-four 
hours, then do the uterovaginal tam¬ 
ponade as thoroughly as possible. 
This will, as a rule, be sufficient to 
cause efficient uterine contractions 
which will expel the mole. If there is 
any doubt as to such expulsion ex¬ 
plore with the finger gently, and 
scrape the uterine wall with its tip. 
The metallic curette is especially dan¬ 
gerous in this case because the uterine 
walls are more or less weakened by 
the invasion of the cystic villi. Occa¬ 
sionally it may be advisable to use a 
dull curette, but this should be con¬ 
sidered a misfortune, and great care 
should be exercised. 


Chorioepithelioma (chorion epithe¬ 
lioma, syncytioma maligntim, de- 
ciduoma malignum, choriocarcinoma). 
—This is a very malignant form 
of epithelioma developed from the 
epithelial layers covering the villi of 
the chorion. It is usually associated 
with abortion, and in 50 per cent, of 
the cases is preceded by hydatiform 
mole. We are told that it may occur 
after labor following full term, but 
the writer has not met such a case. 
Obstetricians have for some time con¬ 
sidered that this form of epithelioma 
is always associated with pregnancy. 
Some surgeons have said recently 
that tumors simulating chorion epi¬ 
thelioma have been found not only in 
women in the absence of pregnancy, 
but also in men, and that all such 
have arisen in pre-existing teratomata. 
Obstetricians, however, do not believe 
that such tumors are really chorio- 
epitheliomata. Metastatic deposits, 
even more malignant than the original 
tumor, soon appear in various parts 
of the body, especially in the vagina 
and lungs. 

Hemorrhage is the earliest and most 
persistent symptom. The flow is at 
first red, but soon becomes dark and 
offensive. The uterus grows rapidly 
and is often perceptibly soft in one 
or more places. A hemorrhage is 
serious when it becomes in the slight¬ 
est degree offensive. Scrapings from 
the uterine wall may be examined 
microscopically. 

Treatment of Chorion Epithelioma .— 

A radical operation is immediately 
indicated. The uterus, appendages, 
and metastatic deposits, especially if 
any be found in the vagina and vulva, 
should be removed. 

INDUCED ABORTION.— Induc¬ 
tion of abortion is very grave in any 


ABORTION (WRIGHT). 


177 


case, and should never he decided on 
without a consultation. 

Indications.—It may be said in a 
general way that, in any case where 
the life of the patient is imperiled by 
the continuation of pregnancy, abor¬ 
tion should be induced. In nearly all 
cases, however, when serious disease 
is present it should receive prompt 
and careful treatment. That death 
of the embryo or fetus is a positive 
indication for the induction of abor¬ 
tion need scarcely be emphasized. 

Tuberculosis. —It was a few years 
ago (and is now we fear) the custom 
of some physicians to induce abortion 
in all pregnant women suffering from 
tuberculosis. We have to consider, 
however, that in the light of our 
present-day knowledge tuberculosis 
is a curable disease in the pregnant 
woman as well as in the non-pregnant 
one. If, then, our patient has tuber¬ 
culosis during pregnancy it is our 
duty to treat the tuberculosis and not 
to murder the unborn child. This 
should be our general rule. In a few 
exceptional cases (and they are very 
few), especially when the morbid 
process is far advanced, the uterus 
should be emptied. 

Cardiac Disease. —In a large majority 
of women who have heart disease, 
pregnancy does not produce effects 
sufficiently serious to justify the in¬ 
duction of abortion. If, however, as 
happens in a small proportion of 
cases, especially when there is mitral 
stenosis, such symptoms as hemop¬ 
tysis, precordial distress, palpitation, 
and great debility appear, and grow 
steadily worse, under appropriate 
treatment, the induction of abortion 
should be considered. 

Excessive Vomiting of Pregnancy .— 

\Ve have recently learned that the 

1 - 


pernicious vomiting of pregnancy is 
due, in some cases at least, to peculiar 
disturbances of metabolism which 
produce a toxemia. Chemical exam¬ 
ination of the urine shows a decrease 
of the amount of nitrogen excreted as 
urea, and an increase of the amount 
excreted as ammonia. In normal 
pregnancy, the quantity of ammonia 
excreted (the ammonia coefficient) is 
4 to 5 per cent. In pregnancy with 
this form of toxemia, it may rise to 
10, 20, or 40 per cent., or even higher. 
Williams thinks that when the am¬ 
monia coefficient exceeds 10 per cent, 
the pregnancy should be immediately 
terminated. We have found, how¬ 
ever, that in some cases the ammonia 
coefficient may considerably exceed 
10 per cent., and the patient may re¬ 
cover without the termination of preg¬ 
nancy. It is hoped that further in¬ 
vestigation will lead to conclusions 
which we shall all accept. We agree 
with Williams to some extent, how¬ 
ever, and believe that when the am¬ 
monia coefficient reaches 10 per cent, 
the patient is in a dangerous condi¬ 
tion, and needs prompt and suitable 
treatment. If in spite of such treat¬ 
ment carried out for one to two weeks 
she grows steadily worse, pregnancy 
should be terminated. 

The practitioner who does not de¬ 
pend on this chemical test should be 
guided by the symptoms and condi¬ 
tion of the patient. Indeed no one 
should neglect a careful study of all 
symptoms. It is very important that 
we should not wait too long. We 
have certainly much to learn yet re¬ 
specting this very perplexing subject. 
We have occasionally found that the 
results of interference even in appar¬ 
ently favorable cases are sadly dis¬ 
appointing. 

-12 


178 


ABORTION (WRIGHT). 


The most frequent conditions de¬ 
manding induction of abortion are 
the toxemias of early pregnancy, per¬ 
nicious nausea and vomiting, and in¬ 
ability to maintain the metabolism 
of the body. Intensive observation 
of these patients is required for com¬ 
puting the total intake and output 
and the total amount of nourishment 
retained for 24 hours. Accurate 
laboratory research is necessary. 
Heart lesions with evidence of de¬ 
compensation also furnish grounds 
for therapeutic abortion. E. P. Davis 
(Therap. Gaz., xliii, 389, 1919). 

General Toxemia of Pregnancy .—No 
definite statement can be made as to 
the exact time when interference is 
desirable in case of general toxemia 
of pregnancy. Apart from excessive 
vomiting in connection with toxemia 
we fear especially eclampsia. Before 
the onset of convulsions the induction 
of abortion is very rarely considered 
necessary. Convulsions,, as a rule, 
do not occur in the early months of 
pregnancy; when they occur in the 
later months an immediate delivery 
is considered necessary. A vaginal 
Caesarean section is probably safer 
than rapid dilatation of the cervix 
with quick extraction. Both opera¬ 
tions, however, are serious, and the 
careful, conservative physician will 
prefer to resort to safer procedures. 
The importance of great haste in 
emptying the uterus has been grossly 
exaggerated in recent years. We 
think this is especially true as to 
eclampsia. 

Chronic Nephritis. — Induction of 
abortion is not, as a rule, indicated in 
cases of chronic nephritis. Occasion¬ 
ally the symptoms grow so serious, in 
spite of suitable treatment, that the 
patient’s life is endangered. Under 
such circumstances the uterus should 
be emptied. Disorders of vision dur¬ 


ing pregnancy are very serious in pa¬ 
tients who have chronic interstitial ne¬ 
phritis. Partial or complete blindness 
in such cases generally indicates a fatal 
termination. On the other hand, one 
may have absolute blindness due en¬ 
tirely to a state of autointoxication. In 
such a case the ophthalmic changes 
are not marked as a rule, and the sight 
generally returns soon after the uterus 
is emptied. Herringham (Brit. Med. 
Jour., May 7, 1910) states that this 
transient form of blindness is never 
found in uremia or associated with 
chronic interstitial nephritis. 

Retinitis .—Affections of the eyes 
should be carefully studied. Retinitis 
should receive prompt attention. If 
the symptoms grow worse instead of 
better after treatment for a few days,. 
interference may become necessary. In 
cases of retinitis with white plaques, 
and dimness or loss of vision, asso¬ 
ciated with serious albuminuria, abor¬ 
tion should be induced at once. Colin 
Campbell (oculist) agrees with Her¬ 
ringham and various modern pathol¬ 
ogists as to the great difference be¬ 
tween a retinitis due to an old chronic 
nephritis and a retinitis caused by 
autointoxication of pregnancy. He 
says the retinitis of pregnancy has a 
bright outlook compared with that of 
nephritis. Examination of the urine 
will materially aid a coming to an un¬ 
derstanding of the condition. “In pre¬ 
existing nephritis the quantity is usually 
greater, the urea and nitrogen more 
nearly full normal, and the albumin and 
casts more abundant. In pre-eclamptic 
cases the uric acid and the amidoacids 
are markedly increased” (Can. Jour, of 
Med. and Surg., Oct., 1910). It may 
be stated in a general way that such 
untoward symptoms occurring early 
are much more serious than similar 


ABORTION (WRIGHT). 


179 


symptoms which may appear late in 
pregnancy. 

Pyelitis. —Pyelitis due to toxemia 
of pregnancy is not very uncommon, 
although, until recently, it was not 
recognized as a separate entity. In¬ 
terference with pregnancy is not gen¬ 
erally required. If, however, the tem¬ 
perature keeps above normal for four 
weeks; if there is much pus in the 
urine; if the leucocyte count is high, 
abortion should be induced. It is 
better if possible, however, to defer 
interference until the child has be¬ 
come viable. 

Antc-partum Hemorrhages. —Hemor¬ 
rhage from placenta prsevia is our chief 
concern in this connection. If inter¬ 
ference becomes necessary we should 
employ the vaginal tamponade, and 
should never dilate the cervix to the 
slightest degree. If the hemorrhage is 
increased by complete or partial sep¬ 
aration of a placenta normally situated 
the same rule as to treatment applies. 
Such hemorrhages do not occur fre¬ 
quently before the child is viable, and, 
consequently, need not be discussed in 
detail here. 

Retroflexion of the Uterus. —When 
serious symptoms appear because of 
retroflexion or retroversion of the 
uterus, and the misplacement cannot be 
corrected, it may become necessary to 
interfere. In the majority of such 
cases abortion takes j!>lace without any 
interference. 

Contracted Pelvis. —The induction of 
abortion in cases of contracted pelvis 
was for a long time considered indi¬ 
cated. We hope it is generally con¬ 
ceded now that such a procedure is 
both incorrect and sinful. We have 
learned in recent years that conservative 
Caesarean section, done at the proper 
time with reasonable care and skill, is 


one of the safest and best operations 
now known to surgery. Such having 
been demonstrated, we have done well 
in ceasing to destroy unborn children 
because of contracted pelvis. 

Hydramnios. —When the hydram- 
nios causes the distention which seri¬ 
ously affects the mother’s health we 
may have to consider the desirability of 
emptying the uterus. In such cases, 
however, we can generally wait until 
the child becomes viable. 

Appendicitis, Ovarian Tumor, and 
Other Abdominal Growths. —Abortion 
should not be induced for any of these 
conditions. The ordinary operation for 
the disease or new growth should be 
performed. 

Goiter. —As a rule there should be 
no interference, at least until the child 
is viable. 

Myoma Uteri. —No interference with 
pregnancy is indicated as a rule. In a 
limited proportion of cases one or more 
fibroids may be so situated that delivery 
in the ordinary way is a physical impos¬ 
sibility; but, even under such circum¬ 
stances, the induction of abortion is 
very rarely indicated. We may, how¬ 
ever, meet a uterus in which the 
growth would interfere with normal 
delivery, but in this case the child might 
be delivered by Caesarean section if 
pregnancy went on to term. Women 
with very bad fibroids seldom conceive, 
and when they do early abortion is apt 
to occur. 

Chorea. —In a certain proportion of 
severe cases of chorea the patient goes 
from bad to worse, notwithstanding 
suitable treatment. In very serious 
cases the woman grows worse very 
rapidly and dies unless the uterus is 
emptied. In many cases this serious 
procedure, unfortunately, does not save 
the patient. 


180 


ABORTION (WRIGHT). 


In many cases pernicious anemia 
in pregnancy seems to be due en¬ 
tirely to the pregnancy. When un¬ 
treated, it usually results in pre¬ 
mature labor, fetal death, or death of 
the mother. In metaplastic anemia 
developing during the first 3 months, 
abortion should be induced at once. 
Later, especially when hypoplastic, 
the patient should be treated medi¬ 
cally at first, and pregnancy inter¬ 
rupted later. A. Frers (Rev. argent 
de obst. y ginec., iii, 430, 1919). 

Method of Inducing Abortion.—For 
the induction of abortion we employ the 
methods and procedures generally used 



Amnionic sac containing embryo and waters. 
The thick decidua retained in uterus. (Seven 
weeks.) 


in cases of inevitable abortion (which 
see). When speaking about the treat¬ 
ment of the latter we had in view the 
fact that nature, chiefly through uterine 
contractions, and hemorrhages, had 
done something, perhaps much, in the 
process of abortion. The ovum has 
been more or less loosened from its at¬ 
tachments, and the cervix has perhaps 
been more or less dilated. In consider¬ 
ing the induction of abortion, we as¬ 
sume, on the other hand, that the ovum 
is pretty firmly attached to its moorings, 
and that the cervical canal is not dilated. 
Under such circumstances it is more 
difficult to empty the uterus. The fol¬ 
lowing recommendations are made for 
the induction of abortion at different 


periods of pregnancy up to the seventh 
month. This course seems advisable, 
although it will mean a certain amount 
of repetition:— 

In any case prepare the patient as for 
vaginal hysterectomy, or as has been 
for curettage, previously described. 



Pregnancy, three months, showing fetus 
below. Placenta formed. 


First or Second Month .—Introduce 
a vaginal tampon of iodoform cheese¬ 
cloth as before described. This may be 
removed, and reintroduced, every 
twenty-four hours for five or six days. 
In many cases these vaginal tampons 
will not produce the desired result, even 
in five or six days. Under such cir¬ 
cumstances one may introduce a narrow 
strip of iodoform gauze within the 
uterus, after the first or second day. 
If, in doing this, one punctures the mem- 



ABORTION (WRIGHT). 


181 


brane, no serious harrri will be done. 
After such introduction, practise vagi¬ 
nal tamponade. It may be necessary 
to do more than the introduction of the 
gauze; if so, adopt the old-fashioned 
method of introducing a uterine sound, 
and purposely puncture the membranes 
if possible. This is suitable, especially 
in cases of pernicious vomiting, because 
such puncture allows the escape of the 
liquor amnii, and such escape often 
causes the serious symptoms to subside 
immediately. It happens that in certain 
cases it is difficult to puncture the mem¬ 
branes because the deciduum is thick, 
tough and elastic. 

Third Month. — Carry out the 
methods recommended for the first and 
second months. There is less chance 
of causing the expulsion of the entire 
ovum and on that account it is not well 
to wait long before invading the interior 
of the uterus. 

Fourth and Fifth Months .—Practise 
a uterovaginal tamponade as before 
described as rapidly and thoroughly as 
possible. 

Sixth and Seventh Months. —Intro¬ 
duce a vaginal tampon, remove in 
twenty-four hours, place patient in 
lithotomy “across bed” position: intro¬ 
duce a weight speculum, seize the 
anterior lip of the cervix, pass a gum- 
elastic or hard-rubber bougie, or a 
medium-sized rectal tube within the 
uterus, between the membranes and 
uterine wall to the fundus if possible. 
Then place woman in Sims’s position, 
and plug vault of the vagina tightly. 
Labor will generally come on in a few 
hours, and the uterine contents will 
soon be expelled. It is sometimes ad¬ 
visable to introduce the bougie in the 
fifth month. 

We find that in some cases the tam¬ 
ponades are not efficient, and we are 


compelled to adopt more forceful pro¬ 
cedures. As before mentioned we think 
the use of the metallic dilator and sharp 
curette in the “single sitting” operation 
is always dangerous. If this statement 
is true, or even half-true, it is sad to 
notice that some of our ablest authors 
in recent textbooks say that “the in¬ 
duction of abortion is practically free 
from danger if perfect asepsis is 
observed.” This operation is especially 
dangerous in the class of cases included 
in this chapter because the patient is 
generally in a bad physical condition 
from the complication which calls for 
the termination of pregnancy, as, for 
instance, pernicious vomiting. 

It is generally an easy matter, espe¬ 
cially after a vaginal tampon has been 
in place twenty-four hours, to dilate the 
cervix with the Hegar dilators suffi¬ 
ciently to allow the introduction of the 
gauze within the uterine cavity. We 
also recommended the use of the 
laminaria (sea-tangle) tent for dilata¬ 
tion. It is said, however, that there is 
great danger of infection from the use 
of any tent for such purpose. There 
was, of course, much reason for such 
fear many years ago when the sponge, 
tupelo and laminaria tents were not 
sterile, and, in addition, were not used 
in an aseptic way; but during recent 
years we have been able to get excellent 
sterile laminaria tents that are perfectly 
safe if used in a cleanly way. 

Similar objections have been raised 
against tampons because they also were 
unsafe as used many years ago, but the 
tampon medicated with iodoform or 
other suitable antiseptic is as safe as 
anything that can be introduced within 
the uterine cavity. It is thought by 
some that there is danger from the use 
of the bougie according to Krause’s 
method, but, if the bougie is made per- 


182 


ABORTION, TUBAL (DEAVER). 


fectly sterile by boiling and is carefully 
used, the danger therefrom is very 
slight. It is well to remember, how¬ 
ever, that there is always some danger 
in connection with any obstetrical 
operation through want of care on our 
j)art. We should ever make a con¬ 
tinuous effort to guard against such 
danger. 

A. H. Wright, 

Toronto. 

ABORTION, TUBAL.— 

DEFINITION. —Early interruption, 
i.e., abortion, is the natural outcome 
of extra-uterine pregnancy, whether 
by reasons of insufficient blood- 
supply or unfavorable mechanical 
conditions for the continued develop¬ 
ment of the fetus. 

[A brief review of the history of this im¬ 
portant subject ought to possess for us more 
than ordinary interest because of the impor¬ 
tant role played in its development by one 
almost of our own number and generation 
in whom we may take a pardonable local 
pride. I refer to the illustrious and lamented 
John S. Parry. He was not the first to write 
upon the subject. Indeed, Albucasis, the 
Arabian, in the eleventh century recognized 
and described a case of extra-uterine preg¬ 
nancy. Nor was he the first to grasp the 
possibilities of operative treatment in the 
emergency of rupture. That was proposed 
by Harbert, of New York, in 1849. The 
merit of Parr}^ consisted not only in grasping 
the significance of the catastrophe and the 
correct mode of meeting the emergency, but 
in applying his philosophical mind and schol¬ 
arly attainments to the production of a mono¬ 
graph which by its masterly marshaling of 
facts and lucidity of deduction should have 
quieted the doubts of Thomas. He was able 
to collect for his book, which was published 
in 1876, 500 cases reported in the literature. 
Of 499, in which the result was stated, 366 
died and 163 recovered. Of the deaths, 174 
had been from rupture. Of these deaths 81 
had died within 24 hours. These figures 
were his text. He began his sermon with 
this sentence: “From the middle of the 


eleventh century, when Albucasis described 
the first known case of extra-uterine preg¬ 
nancy, men have doubtless watched the life 
ebb rapidly from the pale victim of this acci¬ 
dent, but have never raised a hand to help 
her.” Then, though not himself a surgeon, 
he points out the plain surgical indications. 
In the same year as the publication of his 
monograph he died, doubtless depriving the 
world of one who was destined to become 
one of its greatest figures in the advance¬ 
ment of medicine. Parry was a pupil of my 
father, who often used to speak of his stu¬ 
dious habits and scholarly grasp. He was 
by nature fitted for mental leadership. 

The honor of performing the first opera¬ 
tion for this emergency went to Lawson Tait 
in 1883. He had been earnestly solicited to 
operate for this condition in 1881 by a physi¬ 
cian who had correctly diagnosed a case of 
rupture with internal hemorrhage. He re¬ 
fused, and the patient died shortly after. 
Unfortunately the first patient operated on 
died also, but his change of heart was com¬ 
plete, and, correctly attributing his failure in 
the first case to faulty technique, he altered 
his method and continued to operate all such 
cases. Of the next 40 cases only 1 died. 
Truly a brilliant record which was not long 
in converting the medical fraternity. 

The original microscopical preparations of 
Tait in which he demonstrated his ideas on 
extra-uterine pregnancy and pelvic hemato¬ 
cele which, before him, were in a very con¬ 
fused state are still to be seen in the mu¬ 
seum of the Royal College of Physicians in 
London. 

There are many other names of more or 
less importance in connection with the de¬ 
velopment of the subject, but these two are 
central and all we have space to consider. 
John B. Deaver.] 

SYMPTOMS. —The symptoms of 
extra-uterine pregnancy include those 
due solely to the condition of preg¬ 
nancy and those which arise only 
from its abnormal situation. Inas¬ 
much as the majority of cases termi¬ 
nate within three months, at which 
ordinary signs of pregnancy are not 
usually pronounced, we do not often 
get much help from the symptoms 
belonging to the first group. Yet 


ABORTION, TUBAL (DEAVER). 


183 


such symptoms and signs as enlarge¬ 
ment of the breasts, the presence of 
colostrum, cessation of menstruation, 
increased vascularity of the genitalia, 
softening of the cervix and body of 
the uterus with slight enlargement, 
disturbances of the bowels or bladder, 
morning nausea, and the abnormal 
appetite, cravings or sensations which 
the multipara sometimes recognizes, 
are occasionally of confirmatory value. 

It would be desirable to make the 
diagnosis before rupture were it pos¬ 
sible to do so. Unfortunately a large 
percentage of cases give such trifling 
evidence of the true condition, if 
indeed there be any prodromal symp¬ 
toms at all, that no suspicion is 
aroused. Still it is occasionally pos¬ 
sible to make the diagnosis and it 
should be our effort to do so. One 
operator, Baldwin, of Columbus, 
Ohio, has reported 11 such cases. 

Lejars holds that a prolong-ed continu¬ 
ous blood-stained uterine discharge is an 
important aid in differentiating tubal abor¬ 
tion; even if the proportion of blood is 
small its persistence for two up to five 
weeks is characteristic, and absence of 
blood in the vaginal discharge is strong 
evidence against a recent hematocele. The 
slight hemorrhage seems to persist longer 
after tubal abortion than after rupture. 
Incomplete expulsion of the ovum is also 
liable to keep up the hemorrhagic dis¬ 
charge, and the writer relates some in¬ 
stances of such retention of the placenta 
with the tube open and of total retention 
with the tube closed. The small encap¬ 
sulated collection of blood may be taken 
for a fibroma, and the resulting disturb¬ 
ances for inflammatory processes in the 
adnexa or in the uterus. Certain cases of 
tubal abortion have been diagnosed as a 
hemorrhagic metritis, and the uterus was 
curetted when this organ was sound and 
the trouble was in the tube beyond the 
reach of the curette. 

According to Holden a sign of tubal 
pregnancy is a more or less striking pale¬ 


ness of the cervix. The absence of this 
paleness does not, however, exclude this 
condition, but its presence, when not due 
to obvious other causes, is almost pathog¬ 
nomonic. It is only present, however, in 
those cases in which there is bleeding 
from the uterus. Editors. 

The diagnosis in these cases rests 
upon : first, a consideration of the his¬ 
tory. Important points for considera¬ 
tion are the age of the patient, 
exposure to pregnancy and the pre¬ 
sumptive signs and symptoms, a 
history indicative of an antecedent 
tubal inflammation, a previous period 
of sterility usually of some years. 
This last point has been observed by 
all students of the condition and 
Parry remarks on what he calls ‘'the 
previous inaptitude for conception” 
of these patients. 

Amenorrhea of shorter or longer 
duration is a fairly constant feature 
and is followed in the majority of 
instances by irregular bleeding from 
the uterus, sometimes profuse, some ¬ 
times, a mere staining. The history 
of passing bits of tissue or the demon¬ 
stration of decidua in the discharge 
is important. 

Pain if felt before rupture consists 
frequently in vague uneasy sensa¬ 
tions in the pelvis. Sometimes it is 
more severe, colicky in type and ac¬ 
companied by nausea. 

In cases which show any of these 
suspicious symptoms an internal ex¬ 
amination should not be neglected. 
The demonstration of a pelvic mass 
lying outside of the uterus, in the 
presence of a probable pregnancy, is 
a very suspicious circumstance. If 
this mass should correspond in size 
with the duration of pregnancy, if it 
should be located in the course of 
the tube, if it be movable, moderately 
soft and very tender, we may fairly 


184 


ABORTION, TUBAL (DEAVER). 


conclude we are dealing with a case 
of extra-uterine pregnancy. It must 
be remembered that it is sometimes 
easy to mistake a retroflexed preg¬ 
nant uterus for an extra-uterine preg¬ 
nancy. 

A study of 36 cases simulating tubal 
pregnancy by Crossen showed that the 
following conditions may be mistaken for 
it; 1, an acute exacerbation of a dormant 
gonorrheal pyosalpinx; 2, sudden exten¬ 
sion of a uterine gonorrhea to the tubes 
and peritoneum; 3, an early abortion if 
associated with salpingitis or a tumor; 4, 
an irregularly softened, misplaced, hyper¬ 
esthetic uterus associated with tubal en¬ 
largement; 5, an unsuspected tumor asso¬ 
ciated with symptoms of early pregnancy; 
6, ovarian hemorrhage or tubal hemor¬ 
rhage from other conditions; 7, sudden 
and rapidly progressive salpingitis, appen¬ 
dicitis, and gastrointestinal perforations. 

A positive diagnosis of unruptured 
ectopic pregnancy or tubal abortion 
should be made in the vast majority 
of cases. In his service at the Long 
Island College Hospital, and in over 
250 personal cases, a positive diag¬ 
nosis was made in over 85 per cent, 
of the cases. This is due to the fact 
that a very careful history was taken 
and a thorough physical examination 
made in each instance. The condi¬ 
tions, pathological or mechanical, 
that may cause a delay in the prog¬ 
ress of the impregnated ovum are 
always indicated in the history if the 
attending physician or surgeon takes 
the trouble to correlate the facts as 
stated by the patient. The diagnosis 
of ruptured ectopic with the conse¬ 
quent hemorrhage and shock is ob¬ 
viously very much easier to diagnos¬ 
ticate. J. O. Polak (L. I. Med. Jour., 
xii, 121, 1918). 

Often before a diagnosis can be 
made, usually before the diagnosis is 
made rupture of the tube or extensive 
separation and hemorrhage from the 
placental site supervenes. It was 
formerly thought that rupture was 
the most common outcome of tubal 


pregnancy. More careful examina¬ 
tion of the specimens, however, has 
shown us that in many cases df sup¬ 
posed rupture we are dealing with a 
case of tubal abortion with hemor¬ 
rhage from the site of implantation. 
Moreover, hemorrhage from this 
source, while less violent as a rule 
than in rupture, may be very severe 
and even fatal. Frequently, however, 
it is comparatively slow and by slow 
leakage is responsible for the majority 
of hematoceles which we find. Recent 
statistics indicate tliat these tubal 
abortions occur more frequently than 
does rupture. The tragic stage^ how¬ 
ever, may follow either process. 

[The idea that rupture is not so frequent 
as has been supposed and therefore an 
extra-uterine pregnancy is not so danger¬ 
ous a condition is fallacious. It is a mat¬ 
ter of common knowledge that tubal abor¬ 
tion may give rise to a condition as serious 
as any of the accidents of ectopic preg¬ 
nancy. I should not feel it necessary to 
insist on this fact were it not for an im¬ 
pression which is going abroad in regard 
to treatment, which I shall consider later. 
John B. Deaver.] 

There are instances in which a 
strong presumptive diagnosis can be 
made and for lack of which the pa¬ 
tient suffers. There is usually a ces¬ 
sation of menstruation for one or 
more periods, and in this case, wfith 
rupture threatening, it is usually re¬ 
established, irregular as to time, and 
of a tarry, sticky character which, ac¬ 
cording to some observers, is pathog¬ 
nomonic. The pain is usually cramp¬ 
like, occurring at intervals for sev¬ 
eral days, and following it there is a 
dark, sanguineous discharge, probably 
due to a partial rupture of the gesta¬ 
tion sac. Microscopic examination 
will reveal traces of decidua in most 
cases. A careful and thorough exam¬ 
ination is advisable and great care 
should be employed to avoid ruptur¬ 
ing the sac. L. G. Bowers (Jour. 
Amer. Med. Assoc., Feb. 12, 1910). 


ABORTION, TUBAL (DEAVER). 


185 


Pain is a very important symptom. 
It is sudden and acute in its onset; 
is located in the affected tube; is dis¬ 
tinct but rarely very severe prior to 
rupture (Zinke); and the attacks soon 
pass off. It is generally sickening in 
character, and it is usually the one 
symptom which induces the patient 
to visit her physician.' The tubal 
cramps result from an attempt on the 
part of the tube to expel the ovum 
or the blood which has exuded into 
its caliber. Considerable blood may 
escape through the fimbriated ex¬ 
tremity in this way, causing slight 
localized peritonitic attacks with re¬ 
sultant adhesions. The history of 
colicky attacks may cover several 
weeks before the final rupture of the 
sac. A vaginal exploration shows an 
exquisitely sensitive mass lying in 
close juxtaposition to the' uterus, a 
strongly presumptive diagnosis of 
the condition may be made. The 
enlarged tube can readily be palpated 
bimanually in most cases, unless the 
abdominal wall is very rigid or un¬ 
duly thick. Such a tumor is uni¬ 
lateral, in distinction from inflamma¬ 
tory and purulent affections of the 
tubes, and while partially fixed it is 
not firmly adherent, presenting a 
board-like rigidity, as in the case of 
a pus-tube. It can be readily felt 
through the vaginal vault, and is 
commonly the seat of distinct arterial 
pulsation—another feature which is 
generally absent from inflammatory 
conditions of the tube. Borland 
(Jour. Kans. Med. Soc., Nov., 1915). 

Of the 75 cases of bilateral tubal 
gestation reported in the literature, 
about 41 may be considered as sim¬ 
ultaneous gestations. But 8 of these 
cases are doubtful, reducing the fig¬ 
ure to 33 cases. Practically the diag¬ 
nosis of bilateral pregnancy is never 
made before intervention. On inter¬ 
vening for a tubal pregnancy, the 
annex on the opposite side should 
always be examined. If a hematosal¬ 
pinx is found it must always be re¬ 
moved. Proust and Buquet (Rev. de 
gynec. et de chir. abd., xxiii, 353, 
1916). 


Abdominal pain was present in all 
cases, varying from the classical 
crisis with the following shock from 
hemorrhage to the more or less con¬ 
tinued abdominal distress, which 
brought the 36 patients for examina¬ 
tion to the writer. The former con¬ 
dition with its clearcut evidence of 
intraperitoneal hemorrhage is not 
usually mistaken, but the slow process 
with its distress from tubal disten¬ 
tion or slight rupture is very confus¬ 
ing. In a case of irregular bleeding 
and abdominal pain, one must have 
constantly in mind 3 conditions, 
namely, intra-uterine pregnancy with 
threatened abortion; inflammatory 
tubal disease, especially hydrosalpinx 
and pyosalpinx, and extra-uterine 
pregnancy. C. B. Lewis (Jour. Amer. 
Med. Assoc., Sept. 21, 1918). 

In 183 cases of ectopic pregnancy 
sudden onset of abdominal pain oc¬ 
curred in less than half of the cases, 
colicky pains in the lower abdomen 
in a little more than one-third, and 
abdominal tenderness in four-fifths. 
Vaginal examination showed the 
uterus enlarged in nearly one-third, 
and a palpable mass, which was 
usually tender, was found in one of 
the fornices or the cul-de-sac in over 
two-thirds. The temperature on ad¬ 
mission was above 99 degrees in 
nearly three-fifths of the cases. Fever 
was more frequent and rose higher 
in those in which the internal hemor¬ 
rhage was greatest. 

The most frequent error in diag¬ 
nosis was acute or chronic tubal in¬ 
fection, and the next, abortion and 
acute appendicitis. Usually a careful 
history and physical examination will 
lead to a correct diagnosis in un¬ 
ruptured cases. H. F. Lewis (Ills. 
Med. Jour., xxxvii, 301, 1920). 

Rupture is the most serious acci¬ 
dent of ectopic gestation. It may 
take place very early and be the first 
symptom. Cases have been reported 
of rupture in the first or second weeks 
of pregnancy. Usually it occurs in 
the second oi" third months, but occa- 


186 


ABORTION, TUBAL (DEAVER). 


sionally may be delayed into the later 
months. Secondary rupture may oc¬ 
cur at any time after primary rupture 
up to term. Rupture is usually 
ushered in by severe lancinating pain 
in the hypogastrium, accompanied by 
shock, sometimes by syncope and 
frequently by nausea or vomiting. 


of the abdomen vv^hich is readily dis' 
tinguished from the usual rigidity of 
inflammation of the peritoneum. 

There are the symptoms of rupture 
and of hemorrhage per se. They are 
not always so frank and outspoken 
and in order to be sure of our ground 
it is frequently necessary to bring to 


Differential Diagnosis between Extra-uterine Pregnancy and Early 
Abortion Based on a Careful Study of 28 Cases. 


Extra-uterine Pregnancy. 

1. Advent is sudden. 

2. Pain is severe very early. 

3. Blanching of the face early. 

4. Pulse very feeble and rapid early. 

5. Hemorrhage usually not severe, but per¬ 

sists, even after the uterus has been 
thoroughly emptied. 

6. At first there is no elevation of tem¬ 

perature, and later it is rarely above 
101° F. 

7. At one side of the uterus there is usu¬ 

ally a very tender tumor, which is, as 
a rule, movable. 

8. Boggy feeling behind the uterus. 

9. Usually the cervix is very slightly open. 

10. Shreds, decidual membrane and blood 

only escape. 

11. Late there will be marked diminution of 

the hemoglobin (30 per cent, to 70 per 
cent.). 

12. Rarely, if ever, polynuclear leucocytes. 

13. If the cul-de-sac of Douglas is opened, 

blood will escape with possibly an 
embryo. 

Ralph Waldo (Archives of Diag., 


Early Abortion in Uterine Pregnancy. 

Rarely sudden. 

Not severe early. 

Blanching of the face late, if ever. 

Pulse strong and full until late. 

Hemorrhage usually severe early and mark¬ 
edly, diminishes after the uterus is emptied 
and ceases entirely in a few days. 

Frequently, especially if there is sepsis, the 
temperature is very much elevated. 

There is no tumor unless there is infection, 
and then it is rarely movable. 

Not present. 

It is open, especially if part of the products 
of conception are still in the uterus. 

An embryo may be found; if not, the mi¬ 
croscope will show chorionic villi. 

No marked diminution of hemoglobin. 

Frequently present, especially if there is in¬ 
fection. 

No blood will escape. 


Oct., 1908). 


Following this the symptoms of in¬ 
ternal hemorrhages make their ap¬ 
pearance. Increasing pallor, rapid 
and weak pulse, sighing and labored 
respiration and air hunger, dimming 
of vision, with increasing but slight 
distention of the abdomen, signs of 
fluid in the flanks, general abdominal 
tenderness most marked in the hypo¬ 
gastrium and a peculiar doughy feel 


our aid the history and the internal 
examination. In this condition as in 
so many others, the classical picture 
in toto is rarely seen and it has 
happened, paradoxically enough, as 
Douglas remarks, that many more 
diagnoses are made nowadays since 
the integrity of all the classical symp¬ 
toms have been repeatedly attacked 
than when a clear average picture had 


ABORllON, TUBAL (DEAVER). 


187 


been drawn and accepted. It will do 
then to know that the three cardinal 
symptoms are pain, menstrual irregu¬ 
larities and tumor if we appreciate 
their variability. 

Conclusions based on a study of 214 
cases: 1. Irregular flowing seems to 

play the important part given it in the 
books as a symptom of extra-uterine 
pregnancy. 2. The importance of a 
long period of sterility as a cause of 
extra-uterine pregnancy does not seem 
to be borne out by these statistics. 3. 
Conditions possibly leading to extra- 
uterine pregnancy: The fact that cystic 
ovaries, disease of the opposite tube, 
adhesions, or a previous miscarriage 
occurred in over 83 per cent, of 202 
cases is suggestive, and is in agree¬ 
ment with authorities as to the possible 
relation of such conditions to extra- 
uterine pregnancy. 4. The fact that in 
only 26.5 per cent, of 207 cases the pain 
was sudden is of interest. In about 
three-fourths of the cases the sudden 
severe pain was preceded by pain of less 
severity, coming on gradually. 5. Of 
considerable interest is the leucocytosis 
observed in the cases in shock. This 
is apparently a perfect example of leu¬ 
cocytosis after hemorrhage. The find¬ 
ing of a temperature of 100° or over in 
43.4 per cent, of the cases, and of a 
temperature of 101° or over in 14.4 per 
cent, of cases, is also of interest. Ordi¬ 
narily it is supposed these cases rarely 
have any fever. Coues (Boston Med. 
and Surg. Jour., May 11, 1911). 

[The question of great and timely interest 
in connection with the treatment of extra- 
uterine pregnancy has to do with the man¬ 
agement of the case at the time of rup¬ 
ture, with associated hemorrhage and shock. 
Thanks to the early operation these com¬ 
plications are rare nowadays, but I fear, if 
the advocates of delayed treatment secure a 
following in the profession, that these cases 
may occur more frequently, and that cases 
which would be noted in the statistics of 
extreme conservatives as cures will later 
succumb to a condition which is the direct 
result of the Fabian policy. John B. 
Deaver.] 


COMPLICATIONS.— I have al¬ 
ready pointed out that spontaneous 
cures may_ occur without leaving a 
dangerous condition behind and have 
remarked on the rarity of such a 
favorable outcome. More usual is it 
for a collection of blood, often very 
large, to be left as a foreign body in 
the peritoneum. 

These collections or hematoceles 
excite a reactive peritonitis which 
serves to glue together the intestines 
and, encapsulate the mass of clots. 
Absorption and organization of such 
a clot may take place, but is usually 
very slow. In the mean time not in¬ 
frequently infection occurs. The 
danger of this is apparent when we 
realize that an hematocele is nothing 
but a most inviting medium for bac¬ 
terial growth, situated about the 
rectum or lower bowel, which harbors 
the most virulent bacteria. 

[An infected hematocele is a serious con¬ 
dition and demands prompt evacuation and 
drainage. This is best done by way of the 
vagina, if possible. At times it is necessary 
to attack it by the abdominal route, accept¬ 
ing the danger of a subsequent peritonitis. 
John B. Deaver.] 

Obstruction of the bowel is men¬ 
tioned by Parry as the cause of 
death in a number of instances. The 
mechanism of this is by the peritoneal 
adhesions set up by the old extrava¬ 
sation of blood or a degenerated fetus 
in neglected cases. 

Case of extra-uterine gestation sac 
which ruptured into the large intestine. 
A five-months fetus with cord and 
placenta was passed from the rectum, 
and the patient recovered. Martin 
(Miinch. med. Woch., Aug. 21, 1906). 

A pregnancy which is allowed after 
rupture to develop free in the ab¬ 
domen or in the broad ligament later 
furnishes a very difficult problem to 


188 


ABORTION, TUBAL (DEAVER). 


the surgeon owing to the danger in 
dealing with the placental site, and 
the mortality in such cases is much 
higher than in the early cases. Left 
entirely to itself the fetus often be¬ 
comes infected, and the earliest 
records we have of extra-uterine preg¬ 
nancies are of cases in which this oc¬ 
curred, the resulting abscess later 
spontaneously discharging through 
the abdominal walls, when its nature 
was surmised by the appearance of 
degenerated fetal parts in the dis¬ 
charge. Sepsis, exhaustion and death 
were noted in 54 of Parry’s cases. 

A new sign in ruptured extra-uter¬ 
ine pregnancy was identified by the 
writer. The patient, a woman of 38 
years of age, suddenly developed ab¬ 
dominal pain and distention. Three 
weeks later, the umbilical region was 
bluish black, although she gave no 
history of injury. On opening the 
abdomen the writer found a right¬ 
sided extra-uterine pregnancy, and 
about 1^2 quarts of free blood in the 
abdomen. A case is reported by 
Ransohoff, where a man, 53 years of 
age, in whom at operation rupture of 
the common duct revealed much free 
bile in the abdomen. As he showed 
a similar discolored area the writer 
concluded that the bluish black ap¬ 
pearance of the umbilicus in his own 
case was due to intra-abdominal 
hemorrhage, and the presence of the 
nodule to the side of the uterus es¬ 
tablished the diagnosis of extra- 
uterine pregnancy. T. S. Cullen 
(Trans. Amer. Gynec. Soc.; N. Y. 
Med, Jour., Aug. 17, 1918). 

ETIOLOGY AND PATHOGEN¬ 
ESIS.— In attempting to get a clear 
idea concerning the causation of extra- 
uterine pregnancy, one is quite awed 
and overcome by the vast number of 
hypotheses which have been advanced 
to account for this curious anomaly. 

[It is not surprising that there is still 
much obscurity in the etiology. A correct 


understanding of the pathology of any 
condition presupposes a fairly exact 
knowledge of the normal physiology of 
the parts. There still exist many prob¬ 
lems connected with maturation, ovula¬ 
tion, impregnation, implantation and de¬ 
velopment. Some of these problems carry 
us well back into the shadowy realms of 
the beginnings of life itself, that ultima 
Thule of the biologist. 

The incompleteness of our information 
concerning these abstruse secrets of 
nature forces us here, as in so many other 
medical problems, to resort to the meth¬ 
ods of induction and experience, and if 
we have not yet arrived at the point 
where we may safely take the inductive 
hazard it is because we may not yet have 
appreciated fully the saying of old Am- 
broise Pare that “such matters cannot be 
determined by sitting down and thinking, 
but by hard unremitting toil.” 

Gradually, however, our knowledge of 
the normal functions of procreation has 
been expanding and a sufficient number 
of cases have been observed, recorded and 
analyzed to enable us to recognize certain 
factors which evidently play an important 
part in the etiology. John B. Deavek.J 

Lawson Tait originally thought 
that the ciliary current of the mucous 
membrane of the tubes and that of 
the uterus was in opposite direc¬ 
tions, that of the tubes being directed 
toward the uterus and that of the 
uterus moving upward, thus forming 
a natural meeting place of sperm and 
ovum at the fundus. He considered 
it abnormal for spermatozoa to gain 
an entrance into the tubes and held 
that impregnation occurring in the 
tubes through this accidental invasion 
of the spermatozoon was very likely 
to give rise to tubal pregnancy. This 
beautifully simple conception has 
yielded to the iconoclastic power of 
observed facts. We now know that 
the ciliary current of the uterus as 
well as that in the tubes is downward. 
We know that the spermatozoa can 


ABORTION, TUBAL (DEAVER). 


189 


readily stem this current, their rate 
of speed being calculated by Henle 
as 1 cm. in three minutes. 

We know that they quite regularly 
obtain entrance into the tubes and 
swarm up its lumen and it seems 
quite probable, if not certain, that 
impregnation in the tube is common, 
if not the regular method. Once 
fertilization has taken place develop 
ment begins at once. The ovum, 
comparable in many respects to a 
parasite, rapidly throws out the chori¬ 
onic villi which lay hold on the 
maternal tissues and by erosion 
secure anchorage and open up the 
intervillous blood spaces. Just how 
soon the ovum displays these grasp¬ 
ing tendencies is unknown. The 
youngest ovum of which we know 
.was discovered by Peters in the 
uterus of a woman who committed 
suicide three days after missing her 
period. It measured .6 x .8 x 1.3 milli¬ 
meters and was firmly implanted with 
numerous projecting villi in the 
process of formation. Certainly this 
ovum was less than a week old. Just 
what condition must be met by the 
maternal tissues to permit of implan¬ 
tation is uncertain. Webster is quite 
certain that there must be a decidual 
reaction and a number of observers 
have reported having seen decidual 
formation in the tubes. 

Normally the oosperm is swept 
down into the uterus before it effects 
a lodgment. The forces which accom¬ 
plish this movement are the peristalsis 
of the tube and the action of the 
cilia. Whatever delays the ovum in 
transit, permitting it to put out the 
anchoring villi, in the presence of 
a suitable soil, renders imminent 
the occurrence of an extra-uterine 
gestation. 


Analyzing 309 cases, the writer 
found that infection or mechanical 
alteration due to adhesions of the 
Fallopian tube predisposes to ectopic 
gestation. The onset of symptoms 
occurs as frequently at the time of an 
expected period or just after a nor¬ 
mal period as it does when a period 
is overdue. Pain, with or without 
bleeding, was present in every case, 
unless unruptured. L. K. P. Farrar 
(Amer. Jour, of Obstet., June, 1919). 

As to the nature of the soil required 
by the ovum we are not so certain. 
Concerning the influence of delay 
which is governed by mechanical 
causes everyone is agreed. 

These causes may be classified 
as:— 

1. Malformation: as diverticula, 
accessory ostia, and persistence of the 
greatly convoluted fetal contour of 
the tubes. 

2. Obstruction from within: as in 
tubal polypi and torsion of the tube. 

3. Obstruction from without: as in 
myoma and peritoneal bands and 
adhesions. 

4. Inflammation, which acts by de¬ 
stroying the motor power of cilia and 
musculature and secondarily by the 
formation of different types of ob¬ 
struction. 

5. Excessive size of the ovum itself, 
as in the delay which occurs in 
external migration of the ovum. 

The importance of the inflamma¬ 
tory factor in the etiology of ectopic 
gestation is becoming more and more 
appreciated and is even of use in the 
diagnosis, a history indicating more 
or less pronounced salpingitis tending 
to arouse our suspicions of the greater 
possibility of an extra-uterine preg¬ 
nancy in a doubtful case. 

An analysis of 170 cases in the 
author’s clinic showed that tubal preg¬ 
nancy sometimes results from an infan- 


190 


ABORTION, TUBAL (DEAVER). 


tile condition of spiral torsion of the 
tubes, but chiefly from residues of old 
gonorrheal or inflammatory puerperal 
processes. In the diagnosis inflamma¬ 
tory conditions may be differentiated 
from ectopic gestation by the leucocyte 
count and by puncture of the posterior 
vaginal wall. Fehling (Arch. f. Gynak., 
Bd. 92, Hft. 1, 1911). 

According- to the site of implanta¬ 
tion WQ recognize several varieties:— 

1. The interstitial, located in that 
part of the tube -which pierces the 
uterine wall. 

2. The isthmial. 

3. The ampullar. 

4. The infundibular. 

5. The ovarian. 

These are the primary forms. 
Later the gestation sac by reason of 
rupture or growth may change its 
position, giving rise to the secondary 
forms. 

Thus the interstitial form may be 
converted into an intra-uterine by 
rupture into the cavity of the uterus, 
into an abdominal by rupture into the 
general cavity or into an intraliga¬ 
mentary by escape between the layers 
of the broad ligament. The isthmial 
and ampullar forms similarly may 
become tuboabdominal, tubo-ovarian, 
abdominal or intraligamentary. An 
infundibular or ovarian pregnancy 
always tends to become abdominal. 
The last-named condition is one of 
the greatest curiosities of abdominal 
pathology. All the undoubted cases 
of ovarian pregnancy so far observed 
can be numbered on the fingers. The 
interstitial and infundibular forms are 
almost as great rarities; so that for 
practical purposes we have to do only 
with cases primarily isthmial or 
ampullar, of which the latter are most 
numerous, and with the forms second¬ 
ary to these primary varieties. 


Extra-uterine pregnancy assumes 
pathological significance when it 
undergoes ectopic attachment. The 
tubal ovum has a parasitic action, 
malignant in that it destroys maternal 
tissues; it embeds itself in the tube 
wall, and tends to the death of the 
mother. The growth of the ovum or 
the enlargement of the dead ovum 
mass, thinning and destroying the tube 
wall, leads to almost certain rupture 
of the tube. Primary rupture may be 
partial or complete and fatal. If in¬ 
complete, subsequent ruptures will be 
almost certain to follow. With rup¬ 
ture free hemorrhage occurs, which 
may prove fatal. There may be one 
rapid fatal hemorrhage or a series of 
minor hemorrhages. If death does 
not occur from hemorrhage, the blood 
and the ovum in the abdominal cavity 
may act as imitating foreign sub¬ 
stances which lead to loss of function 
and pathological changes in the vis¬ 
cera, to local or general infection, 
thrombosis, embolism, etc. The dead 
ovum is almost as harmful as the liv¬ 
ing one, from the standpoint of rup¬ 
ture, and may be more harmful as a 
focus of infection. C. W. Barrett 
(Amer. Jour, of Obstet, June, 1911). 

Report of a case in which the ovary 
was removed on account of supposed 
cystic enlargement. A fetus was 
found in it, the ovarian elements hav¬ 
ing nearly all been superseded by the 
intact developing ovum. W. Liebe 
(Monats. f. Geb. u. Gynak., Feb., 
1921). 

The natural outcome of extra-uter¬ 
ine pregnancy, as stated in the defini¬ 
tion, is early interruption, whether by 
reasons of insufficient blood supply 
or unfavorable mechanical conditions 
for the continued development of the 
fetus. 

The most common event is the 
formation of a tubal mole from the 
slow leakage of blood about the sac. 
This soon results in the death of the 
fetus and cessation of growth. In 
this way spontaneous recovery may 


ABORTION, TUBAL (DEAVER). 


191 


occur. I have several times in the 
course of pelvic operations encoun¬ 
tered old tubal hematomata which 
were clearly the result of a pre¬ 
vious tubal pregnancy which had 
terminated itself and retrogressed 
without giving the patient any great 
inconvenience. That this is not a 
frequent occurrence our clinical ex¬ 
perience and the infrequency of such 
operative findings testify. There is 
evidence to show that even after the 
death of the fetus the chorionic villi 
may continue to grow and exert an 
erosive action on the wall of the tube 
which, coupled with the distention 
due to hemorrhage, may bring about 
a rupture. More common than this 
is the gradual extrusion of the mole 
from the fimbriated extremity, a 
process known as tubal abortion. 
Rupture of the tube and tubal abor¬ 
tion may take place rapidly without 
the previous formation of a mole. 
These are apt to be the fulminating 
cases. 

Hemorrhage is more free in case of 
rupture than in abortion as a rule: 
more free in rupture into the general 
abdominal cavity than in rupture into 
the broad ligament, more free when 
the site of rupture involves the pla¬ 
cental attachment, and more free at 
the cornual end of the tube than at 
the ampullar end. 

[This latter tendency was tersely expressed 
by Formad, who used to say, “Ruptured 
cornual cases belong to the coroner; rup¬ 
tured ampullar to the surgeon.” Surgery in 
its march has modified this statement, but it 
still serves to point out the relative dangers. 
John B. Deaver.] 

Hemorrhage is the outcome of 
extra-uterine pregnancy which chiefly 
concerns us from a practical stand¬ 
point. It is probable that no case of 


ectopic gestation occurs which is not 
accompanied by hemorrhage at some 
time. It may, however, be early or 
late, slow or rapid, slight in amount' 
or profuse. It is the chief, though 
not the only, factor in the production 
of so-called shock, and is the main 
agent in a fatal outcome. I shall 
have more to say concerning hemor¬ 
rhage under the question of treat¬ 
ment. 

If the patient be fortunate enough 
to survive the primary rupture and 
the fetus live, she still has to face the 
possibility of a second rupture of the 
gestation sac in its new position. 
Occasionally an extra-uterine preg¬ 
nancy may progress to term. Usually 
this is rendered possible by the escape 
of the fetus within its amniotic sac 
into the general abdominal cavity, 
the placenta remaining attached at 
the primary site. In this event, after 
a spurious labor at term, the fetus 
dies and offers an inviting site for in¬ 
fection. 

[Operation is here indicated on the same 
principle as in the case of any foreign body 
which threatens the host. This holds true in 
spite of the well-known fact that in some 
instances the fetus has caused little harm, 
being converted into a lithopedion or adi- 
pocere. Such a late terminal event presup¬ 
poses a series of diagnostic failures which 
we trust, now that the condition is so well 
known and understood, may not come to 
pass. John B. Deaver.] 

TREATMENT.—This involves a 
discussion of the immediate consider¬ 
ations concerning an active versus 
expectant mode of treatment in cases 
of rupture. 

[It has long been my practice to operate 
every acute case of extra-uterine pregnancy 
without delay and my results have been so 
uniformly good that it would never have 
occurred to me to reopen the question. 
Robb, in 1907, came forward with the as- 


192 


ABORTION, TUBAL (DEAVER). 


sertion that surgeons- were losing many of 
their desperate cases from overhaste in 
operating during shock. He believes that 
. shock is mainly due to the effect of the acci¬ 
dent of rupture upon the nervous system, 
that it would be a great rarity for a patient 
to bleed to death and that cases in which the 
loss of blood in itself would be sufficient 
to bring about a fatal termination would 
seldom be seen in time to save the patient. 
He bolsters his position by animal experi¬ 
ments, having observed that dogs do not die 
of hemorrhage even after section of the 
uterine and ovarian vessels. 

Just what he considers the cause of death 
in these cases is not clear. The coroner’s 
statistics of Dr. Formad, though he admits 
that it is on record that in certain instances 
the amount of blood which was found was 
enough to fill the abdominal cavity, Robb 
dismisses by saying that “such statements 
are entirely too meager to give us any def¬ 
inite knowledge, nor can they be entirely 
depended on.” He also says in this regard 
that “in a given fatal case it must also be 
proven that there were no other and possibly 
equally important factors in the causation of 
the fatal result.” He not only doubts that 
the coroner saw the blood, but he invites us 
to prove that the patient did not die of cere¬ 
bral apoplexy instead of abdominal hemor¬ 
rhage. As for the animal experiments I can 
only say that, if he has not seen a woman 
die from hemorrhage from a uterine artery, 
he has been more fortunate than I have been, 
and that I therefore still resort to the old- 
fashioned expedient of tying as secure a 
knot about that vessel as I am able. John 
B. Deaver.] 

Formerly it was not such an un¬ 
common thing for these patients to 
bleed to death. Of the 500 cases 
reported by Parry there were 336 
deaths, 174 of which were from 
rupture and hemorrhage. Of 113 of 
these in which the time of death was 
stated 81 had died at the end of 24 
hours and at the end of 48 hours only 
15 were left alive. 

Of course this gives a greatly ex- 
aggerated idea of the danger because 
in those days only the evident and 


severe cases were noted. Still it 
serves to show that, without opera¬ 
tion, death, which was shown by 
autopsy to be associated with exces¬ 
sive hemorrhage, was not so un¬ 
common a sequel. If these deaths 
were not due to hemorrhage, what 
did cause them? 

[Has anyone seen a death from shock of 
rupture with an,insignificant or even a mod¬ 
erate amount of blood in the peritoneal cav¬ 
ity? In the cases which I have seen in this 
so-called state of shock, the condition of the 
patient bore a striking parallelism with the 
amount of blood found in the abdominal 
cavity. I wish to enter a strong protest 
against the loose use of the term shock in 
this condition as well as the vicious tendency 
of such flashy phrases as “adding shock to 
shock. John B. Deaver.] 

The great danger in these cases 
is not from the shock of rupture, 
but from the subsequent hemorrhage. 
Or, to be very conservative, severe 
hemorrhage is necessary to produce 
the fatal outcome. Let us consider 
for a moment this factor, shock. It 
is known that any acute lesion of the 
peritoneum produces, through shock 
to the great abdominal nerve centers, 
a certain train of symptoms, whether 
the lesion be due to rupture of the 
appendix, twisted pedicle of an ova¬ 
rian tumor, passage of gall-stones, 
acute strangulation of the intestine, 
or rupture of an extra-uterine preg¬ 
nancy, and to this train of symptoms 
Giibler has given the name “perito¬ 
nism.” These symptoms are inde¬ 
pendent of inflammation or of septic 
intoxication. They are: pain, pro¬ 
found exhaustion, distressful anxiety, 
pallor; soft, quick pulse ; cold extremi¬ 
ties, shallow respiration, nausea and 
vomiting. These vary in degree and 
are common in some degree to all 
cases in which there has been a wide 


ABORTION, TUBAL (DEAVER). 


193 


and abrupt impression upon the nerve 
centers of the abdomen. This is the 
train of symptoms which follow im¬ 
mediately upon an acute rupture of 
the gestation sac and gives the picture 
properly denominated as shock. This 
shock as such is practically never 
fatal. Clinical evidence is conclusive 
on this point. We do not find our 
patients dropping over dead from 
acute strangulation, twisted pedicles 
or tubal i:uptures. The shock exerts 
its maximum influence at the moment 
of the tearing injury to the perito¬ 
neum and sympathetic trunks and 
practically ceases at once with the 
release of tension after the laceration 
has been effected. This factor is 
sudden, momentary, expends its 
energy and ceases. Reaction begins, 
or would begin at once, either spon¬ 
taneously or with the aid of stimu¬ 
lants. This sudden insult to the 
peritoneum and the great sympathetic 
centers is not what places the patient’s 
life in jeopardy and holds her hover¬ 
ing in the balance for hours. 

This is but the advance agent of 
the real executioner, hemorrhage. 
Read in the same order as before, 
leaving oflf the pain in the beginning, 
we have in the symptoms of shock the 
symptomatology of hemorrhage : Pro¬ 
found exhaustion, distressful anxiety, 
pallor; soft, quick pulse; cold extrem¬ 
ities, shallow respiration, air hunger, 
nausea and vomiting. 

[Who is that man who will tell us in these 
cases where shock leaves off and hemor¬ 
rhage begins to play the leading role ? I feel 
most strongly that we are dealing here with 
a wrong use of words, that there is a 
sophistical “nigger in the woodpile.” I do 
not believe that the patients reported by the 
advocates of the expectant treatment as suf¬ 
fering from shock were suffering from pri¬ 
mary shock, but instead from shock plus 

i- 


hemorrhage, and that, by the time they were 
seen by the surgeon, that hemorrhage was 
playing by far the chief role. Those patients 
who are fortunate enough to lose but a 
small quantity of blood at the time of rup¬ 
ture react from the shock with considerable 
promptitude. By the time proper surgical 
intervention can be brought to bear, their 
condition is such as to give the surgeon little 
immediate anxiety as far as the shock of 
operation is concerned. These patients 
should be operated at once on account of 
the danger of secondary rupture or a re¬ 
newal of bleeding. They should all get well. 
John B. Deaveu.] 

An immediate operation detracts 
nothing from the chances, but guards 
against imminent danger. Those 
patients who, when seen an hour or 
several hours after rupture (I am 
speaking of conditions as we find 
them, for patients do not come to a 
hospital or doctor’s office to be handy 
at the time of rupture), are hanging 
in the balance with the symptoms 
some are pleased to call shock are 
not suffering from shock, but rather 
of shock plus hemorrhage, shock in 
small type, hemorrhage in large red 
capitals, and the examples of reaction 
are not proofs of the wisdom of wait¬ 
ing, but of the fact that many desper¬ 
ate cases will stop just short of bleed¬ 
ing to death if left to themselves, a 
fact which has for years been patent 
to all. 

After operation for tubal pregnancy 
patients became again pregnant in 
35.19 per cent, of the cases, but only 
18.5 per cent, of these are extra- 
uterine. Out of 4526 cases of tubal 
pregnancy a recurrence was reported 
in 4.68 per cent. H. A. Dietrich 
(Zentralbl. f. Gynak., Apr. 9, 1921). 

There are certain factors which 
would favor the cessation of bleeding, 
such as a long and voluminous sig¬ 
moid or omentum wedging down in 
the pelvis, but, as we are not often 

13 


194 


ABORTION, TUBAL (DEAVER). 


furnished with a diagram of interior 
arrangements in these cases, we do 
not know whether these stanch allies 
are on the ground. The character of 
the rent and the coagulability of the 
blood we cannot estimate. 

[As sure as there are immutable laws of 
hydrostatics and of the circulation of the 
blood, these patients have died in the past in 
considerable numbers from hemorrhage and 
occasionally die today from that cause, and 
the only reason more do not die of it is be¬ 
cause of the early operation practised by 
clinical surgeons. 

I am willing to grant that a patient should 
not have a “penknife” operation done on her 
before she has recovered from her first faint. 
There is reason in all things. It is equally 
true that a patient in articulo mortis should 
not be subjected to operation. “The re¬ 
sources of surgery are rarely successful 
when practised on the dying. These princi¬ 
ples, however, should not be made use of 
to attack a mode of treatment which has 
been crowned with the highest success.” 
John B. Deaver.] 

The treatment of unruptured ec¬ 
topic is operative as soon as the 
diagnosis has been made. After 
rupture has taken place, operation 
should be postponed until the patient 
has recovered from the shock inci¬ 
dent to the hemorrhage following 
rupture. Almost all of these patients 
will “come back” with rest and mor¬ 
phine. They are given an initial dose 
of 1-4 grain (0.03 Gm.) of morphine, 
followed by grain (0.016 Gm.) 
every 3 hours until the respirations 
are reduced to from eight to twelve 
per minute. The writer has yet to 
see a case which has not reacted and 
become a safe operable risk under 
this treatment. 

The operation is always done by 
the abdominal route and the tube 
either emptied of its contents or am¬ 
putated. In the removal of the tube 
great care should be exercised in in¬ 
dividually ligating the vessels in the 
mesosalpinx so that the collateral 
circulation to the ovary is not inter¬ 
fered with. “After the tube is re¬ 


moved, the ovary is suspended by 
suture of the infundibulopelvic liga¬ 
ment to the round ligament and the 
raw surface at the top of the broad 
ligament peritonealized by whipping 
the mesosalpinx and round ligament 
together. J. O. Polak (L. I. Med. 
Jour., xii, 121, 1918). 

My position then is this: A con¬ 
tinuance of the collapsed condition, 
commonly, and as I believe erron¬ 
eously, termed shock, for a longer 
time than one hour indicates that 
a considerable hemorrhage has oc¬ 
curred and may be continuing. The 
surgical indications are clear—stop 
the bleeding; stimulate. Let us not 
revert to the dark ages in the ranks 
of those who “watched the life ebb 
rapidly from the pale victim of this 
accident, but never raised a hand to 
help her.’^ 

According to Schauta, the maternal 
mortality in non-operative cases is 68.8 
per cent. The writer is inclined to feel 
that this percentage is too high, that 
more cases of ectopic gestation escape 
recognition and live than we have sus¬ 
pected. At the Columbus Hospital op¬ 
eration is always resorted to, and, per¬ 
formed speedily and promptly, should 
not give a mortality of over 2 per cent. 
The dangers are from shock, hemor¬ 
rhage, sepsis, exhaustion, and intestinal 
obstruction. J. M. Keyes (N. Y. Med. 
Jour., Aug. 6, 1910). 

Since 1900 I have had 110 cases 
of extra-uterine pregnancy, many of 
them of the acute type, without a 
death. 

My procedure in these urgent cases 
is as follows: If the condition be 
very low, stimulation is begun on 
admission by hypodermoclysis and 
strychnine. If there is extreme rest¬ 
lessness, morphine is a valuable ad¬ 
junct administered, of course, with due 
discretion. 












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ABORTION, TUBAL (DEAVER). 


They are placed on the table with 
as little disturbance as possible and a 
light quick etherization given. Prep¬ 
aration is rapidly completed and 
intravenous transfusion of normal 
saline solution started as the abdom¬ 
inal incision is made. “Get in quickly, 
get out quicker” applies here as forci¬ 
bly as anywhere in surgery. The 
offending tube and ovary are re¬ 
moved. The clots are scooped out, 
and, if the condition of the patient 
warrants, the abdomen is flushed out 
and filled with normal saline before 
closure. 

The writer divides ectopic gesta¬ 
tions into 4 groups, viz., with neg¬ 
ligible, moderate, severe, and fatal 
hemorrhage. Patients of the first 
group frequently recover spontane¬ 
ously. If the hemorrhage is discov¬ 
ered, the operation can be deferred 
until the peritoneal irritation sub¬ 
sides. In the third group, shock is 
great. The pain should be relieved 
by morphine, the head lowered, and 
the extremities bandaged. A donor 
should be procured for a blood trans¬ 
fusion, which is to be started before 
the incision is made in the abdomen. 
The fourth group of cases bear trans¬ 
portation poorly. Infusing these pa¬ 
tients with saline solution to which 
6 per cent, gum acacia has been added 
will restore the circulation until the 
patient can be taken to the hospital. 
Hermann Grad (Trans. N. Y. Acad, 
of Med.; Med. Rec., Dec. 4, 1920). 

I have frequently seen the patient 
go off the table with a far stronger 
pulse and in better condition than 
before the operation, a sufficient ref¬ 
utation of the charge of “adding 
shock to shock.” I have rather re¬ 
fused to allow hemorrhage to be 
added to hemorrhage, and now I am 
not afraid to fill her vessels with suffi¬ 
cient fluid to satisfy the mechanical 
needs of the circulation. 


195 

[My last case before this article was writ¬ 
ten happened to be most appropriate to this 
discussion: A young woman, aged 24, mar¬ 
ried three years, with nothing of note in her 
past history. She had had one child nine 
months ago, which died in January. No 
miscarriages. Menstruation had always been 
regular and normal up to her January 
period, which she missed. At the February 
period she bled quite profusely and for a 
longer time than usual. No staining since. 

Suddenly at 6 a.m. on February 12th, dur¬ 
ing coitus, she had an acute pain in the lower 
left side of the abdomen, followed in a few 
minutes by syncope. Soon she recovered, 
but fainted several times in the course of the 
morning, and vomited several times. Grad¬ 
ually grew weaker and grew short of breath. 
On examination she did not have a particle 
of color in her skin or lips. Expression was 
anxious: she was restless and dyspneic. 
The pulse was about 180 and barely per¬ 
ceptible. Her abdomen was moderately dis¬ 
tended and tender in left side low down. 
Vaginal examination was negative except for 
tenderness in the left lateral fornix. 

She was taken to the operating room and 
subcutaneous infusion started with the ether. 
Preparation having been quickly accom¬ 
plished, the operation and intravenous trans¬ 
fusion were started together. A left-sided 
tubal pregnancy (see colored plate) the size 
of a hickory nut was found in the isthmial 
portion about 2 cm. from the cornual ex¬ 
tremity. Through the tube was a perfora¬ 
tion only about as large as a pinhead. No 
time was wasted in determining whether 
there was any active bleeding. Tube and 
ovary were removed. As the patient’s con¬ 
dition was improving on the table, I washed 
out the blood, of which there was a large 
quantity, and filled the abdomen before clos¬ 
ure with salt solution. 

Her pulse, which before the operation was 
180, at the end of the operation was 140 and 
much improved in quality. She was put back 
in bed and continuous proctoclysis started. 
John B. Deaver.] 

I wish to call attention to the value 
or rather necessity of filling the 
empty blood-vessels with saline in 
these depleted cases. In the above 
case, the amounts used were as fol¬ 
lows : By hypodermoclysis at the 


196 


ABSCESS (WITHERSTINE). 


beginning, 1000 c.c. Intravenous 
transfusion during the operation 2000 
c.c. Left in the abdomen at least 
1500 c.c. Then in the twelve hours 
after operation her thirsty vessels 
absorbed by way of the large bowel 
4000 c.c. additional. Nearly nine 
liters of saline, over two gallons of 
fluid to meet the mechanical needs of 
the circulation. Without this saline 
my patient would have run grave 
danger of dying on the table. As the 
intra-abdominal pressure is released 
by incision the blood flows into the 
“splanchnic tank” and from the great 
depletion due to hemorrhage nothing 
is left in the great vessels for the 
heart to pump. The medullary 
vessels are asphyxiated and death 
results. This restoration of the fluid 
volume of the blood is a most impor¬ 
tant point. 

In 12 out of 135 operative cases of 
extra-uterine pregnancy, the writer 
reinfused into a vein 300 to 1000 c.c. 
of the woman’s own blood, diluted 
with an equal amount of physiologic 
salt solution with a little sodium 
citrate. The blood was scooped or 
soaked up from the abdominal cavity, 
passed through a funnel over some 
gauze as a filter, and then into a 
receptacle containing salt solution. 
One woman died of peritonitis—the 
only death in 12 cases. Von Arnim 
(Zentralbl. f. Gynak., Nov. 29, 1919). 

The writer has likewise had good 
results from reinfusion of blood in 
tubal abortion or rupture of the 
spleen. He punctures the abdominal 
wall in the lower third of the rectus 
muscle and aspirates, to confirm the 
presence of fluid blood. The infusion 
tube is introduced into the vein by 
the assistant as the abdomen is being 
opened. The parietal peritoneum is 
then drawn up into a cone and the 
blood around the bladder runs out. 
From one-half to 1 liter of fluid blood 
is thus secured in a few minutes, 


strained, citrated and poured into the 
infusion funnel. KulenkampflF (Zen¬ 
tralbl. f. Gynak., Apr. 17, 1920). 

John B. Deaver, 

Philadelphia. 

ABSCESS.— DEFINITION.—A 

circumscribed collection of pus in an 
adventitious cavity, the result of local¬ 
ized inflammation due to infection by 
pus-forming microbes, differing from 
diffuse suppuration which is not cir¬ 
cumscribed and from purulent effusion 
or empyema which is found in a natural 
or pre-existing cavity, as the pleura, 
pericardium, mastoid cells, etc. 

VARIETIES.—An abscess may be 
acute, or warm, when due to pus- 
microbes only: staphylococci, strepto¬ 
cocci, and others; chronic, or cold, when 
due to a specific microbe, especially 
that of tuberculosis. 

Abscesses have been classified ac¬ 
cording to:— 

1. Etiology. — Atheromatous, em¬ 
bolic, fecal (stercoraceous), metastatic, 
miliary, ossifluent, puerperal, pyemic, 
residual, symptomatic or congestive, 
tropical, tubercular (strumous, lym¬ 
phatic, or scrofulous), etc. 

2. Pathology. — Acute or warm, 
canalicular, caseous, chronic or cold, 
critical, gangrenous (anthrax), lig¬ 
neous, perforating, phlegmonous, etc. 

3. Location (Organ or Tissue In¬ 
volved).—Alveolar (gum, jaw, teeth), 
of axilla, bone, (subperiosteal), brain 
(cerebral, cerebellar), bursal, corneal 
(hypopyon), deep, dorsal, follicular, 
hepatic, of hip-joint, iliac, ischiorectal, 
lacunar, lumbar, mammary (milk, weid 
or weed, breast), marginal, mediastinal, 
meningeal (extradural, subdural), of 
neck, nephritic and perinephritic, of 
nose, of palate, palmar, of pancreas, 
perityphlitic, popliteal, of prostate, 
psoas, rectal, retropharyngeal, of skin 


ABSCESS (WITHERSTINE). 


197 


(furunculosis), of scalp, of space of 
Retzius (properitoneal cavity), spinal 
or vertebral, of spleen, superficial, 
thecal, urethral and periurethral, vulvo¬ 
vaginal (Bartholinian), etc. All the 
above varieties will be considered under 
their respective anatomical heads. 

ACUTE, OR WARM.—Symptoms. 
—An acute abscess may be either su¬ 
perficial or deep. When it is superficial 
the local symptoms predominate; when 
it is deep the general symptoms are 
more marked. 

The pain, due to compression of the 
nerves by the disturbed tissues, varies 
in degree with the density of the parts 
involved, the local supply of sensitive 
nerves, and the tension produced by the 
inflammatory products. In superficial 
abscess the pain is generally localized 
in the center of the swelling, and is 
sharp and lancinating; in deep abscess 
it is more diffuse and dull. 

Redness is due to engorgement of 
the local blood-supply, and the swelling 
to the inordinate distention of the ves¬ 
sels and the secondary escape of blood- 
plasma, colorless corpuscles, etc., into 
surrounding tissues. It may become 
very great in certain regions, such as the 
lids, the lips, etc., in which the cellular 
tissue is lax. As the purulent foci run 
together and form a single cavity, the 
center of the tumefaction becomes soft, 
and darker in color, and the abscess is 
said to be “pointing.” 

Edematous infiltration in superficial 
abscess denotes the presence of pus; in 
deep abscess subcellular edematous in¬ 
filtration is an important sign of deep 
suppuration. 

Local heat, throbbing, and tension are 
mechanical results of the causes of tu¬ 
mefaction tending to decrease as the 
formation of pus progresses. 

Hyperpyrexia is in relation with the 


location of the abscess, the ease with 
which the pus-microbes can enter the 
circulation, and the amount of pus and 
necrotic tissues present. In superficial 
abscess there is but little rise of tem¬ 
perature, but in deep abscesses it some¬ 
times reaches 104° F. (40° C.) at the 
time the wall of granulation tissue is 
established. A remission of about one 
degree each morning usually takes 
place. When the pus has found an 
issue, or has become completely sur¬ 
rounded by the limiting membrane, the 
intensity of the fever is usually 
reduced. 

In a superficial abscess, if a chill oc¬ 
cur, it is usually very slight, and ap¬ 
pears between the fourth and the eighth 
day. It indicates the formation of pus. 
In a deep abscess a chill generally 
occurs, lasting from a few moments to 
half an hour. 

Fluctuation is generally obtained 
when the purulent focus has been 
formed. A sharp localized pain on 
pressure over the apex of the swelling 
obtained at this time supports the likeli¬ 
hood that pus is present, but fluctua¬ 
tion is liable to be a misleading 
symptom. 

Interference with motion or the 
normal functions of a part is sometimes 
produced through the proximity of an 
abscess. 

In deep-seated abscess any or all of 
the general symptoms of abscess may 
be lacking, except loss of flesh and 
strength. This is especially true of 
hepatic or cerebral abscess. The symp¬ 
toms usually present are local tender¬ 
ness and pain, pressure symptoms, 
overlying edema, brawniness, muscular 
rigidity and ankylosis of neighboring 
joints, in addition to the symptoms of 
acute suppuration—fever, chills, sweats, 
anorexia, restlessness, etc. 


198 


ABSCESS (WITHERSTINE). 


Etiology.—Inflammation due to trau¬ 
matisms and lesions of all kinds, espe¬ 
cially the introduction of foreign bodies 
under the epidermis, are the usual 
causes of abscess. While blows do not 
apparently produce superficial lesions 
in the majority of cases, the fact 
remains that an invisible abrasion may 
be present and serve as a channel for 
the introduction of the pyogenic organ¬ 
ism. The cutaneous glands, through 
weakened local resistance, may also 
become the transmitting media. Any 
cause removing the epithelial layer of 
the mucous membrane may also form 
the primary etiological factor of an 
abscess in the membrane or in the sub¬ 
mucous connective tissue. Abscesses 
also arise in connection with the various 
septic fevers. 

The writer refers to 2 cases of 
inflammatory newgrowths of ex¬ 
tremely slow development which had 
led to the diagnosis of cancer. They 
were hard and located in the ab¬ 
domen in both instances. The pa¬ 
tients were men of 26 and 72. The 
tumors were observed 4 years and 3 
months, respectively, and both were 
permanently cured by clearing out 
the focus. There was a history of 
operative treatment for inguinal her¬ 
nia not long before in each case, but 
in the younger man unsuspected ap¬ 
pendicitis was probably the main fac¬ 
tor. In both cases only the ordinary 
pyogenic germs were found. Filardi 
(Policlinico, Aug., Surg. Sect., 1917). 

The three essentials in the formation 
of an abscess are: pyogenic organisms 
in sufiflcient numbers and virulence, their 
proper implantation within the tissues, 
and a sufficiently low resisting power, 
either local or general. 

Pathology.—While several varieties 
of micro-organisms are found in the 
pus of an acute abscess, the principal 
ones which ordinarily cause purulent 
inflammation are the Staphylococcus 


pyogenes {aureus and albus), Strepto¬ 
coccus pyogenes, Micrococcus gonor- 
rhcece, Bacterium coli commune, Bac¬ 
terium pyocyaneum, pneumococcus, and 
the Sarcina tetragena. Less frequent in 
the production of suppuration are the 
typhoid bacillus, the influenza bacillus, 
the diphtheria bacillus, the actinomyces, 
etc. 

An acid-fast bacillus was culti¬ 
vated by the writer from chronic in¬ 
tractable pustules covering the back, 
buttocks, and thigh of a soldier re¬ 
turned from France. No micro¬ 
organisms were seen in the pus, and 
none could, at first, be cultivated 
from it. But subsequently there was 
grown, on more than one occasion, 
the acid-fast bacillus referred to. 
Cobbett (Brit. Med. Jour., Aug. 17, 
1918). 

According to Kreibich suppuration 
can occur in man without the presence 
of bacteria. Both in animals and in 
man, suppuration may be due to the 
irritation of chemicals. Investigators 
have shown that suppuration is only 
a certain stage of inflammation, not a 
separate qualitative form of inflamma¬ 
tion. The serous formation of blebs 
and bullae becomes purulent without 
the presence of bacteria. 

Chronic suppurative processes are, 
according to Lyman Allen, very fre¬ 
quently unattended by fever, while 
acute suppurative processes are fre¬ 
quently unattended by fever. In a 
given case, therefore, the absence of 
fever must have little weight by itself 
in excluding the possibility of suppu¬ 
ration. Since a rise of temperature 
above 100° F. occurs in about two- 
thirds of all aseptic cases, the pres¬ 
ence of fever alone must have little 
weight in making a diagnosis of sup¬ 
puration. 

Suppuration is almost invariably pre¬ 
ceded by inflammation due to the 


ABSCESS (WITHERSTINE). 


199 


pyogenic micro-organisms. The first 
effect of the bacterial toxins on the local 
circulation is to cause an increased 
rapidity of the flow of blood in the 
part, the vessels becoming engorged and 
dilated. This is succeeded by slowing 
of the current and passage through the 
vascular walls and into the surrounding 
tissues of colorless corpuscles (leuco¬ 
cytes), a few red corpuscles, and blood- 
plasma, the latter of which become 
coagulated and finally softened. One 
or several cavities are thus formed; but, 
if the cavities are multiple, the barriers 
usually soften and a single focus is 
established. The pus is composed of 
the corpuscles which perish in the 
cavity thus formed, the broken-down 
remains of tissue, and the plasma. At 
a distance from the location of the 
abscess the circulation is normal, but, 
as the diseased area is approached, the 
slowing of the blood-current becomes 
gradually more evident, until a zone of 
living leucocytes is met, forming a pro¬ 
tective barrier around the abscess 
cavity. The surrounding parts also 
become permeated with new vessels, 
and a zone of granulation tissue (the 
pyogenic membrane of older writers) is 
formed. The spread of the suppuration 
being thus checked, the pus is forced 
to the surface because it finds the least 
resistance in that direction; but, if an 
aponeurosis or fascia interfere, it bur¬ 
rows until an exit is found. 

The role of the white corpuscles (leu¬ 
cocytes) has been interpreted in various 
ways; Cohnheim considered them as 
elements of repair; others have attrib¬ 
uted to them the role of scavengers. 
The accepted theory at present, how¬ 
ever, is that of Metchnikoff, who con¬ 
siders them able to attack and destroy 
invading organisms. The process is 
termed by him phagocytosis, the cells 


being called phagocytes (<^ayw, to eat, 
and KVTos, a cell). 

The dead leucocytes in pus must be 
looked upon as the cells that have been 
brought up rapidly to interfere with the 
spread or diffusion of the products of 
the micro-organisms; a large number 
of these cells coming in contact with 
the poison in a concentrated form may 
succumb to its action; but before doing 
so they are able to deal with a certain 
quantity of the poisonous material, 
breaking it down and rendering it inert. 
Other cells are constantly being brought 
up to assist these, until, at length, the 
bacteria are completely hemmed in. 
They live for a short time on the dead 
tissues; but, being localized by the 
barrier of leucocytes, they ultimately 
die, either from inanition or because 
they are poisoned by their own prod¬ 
ucts or by immunizing constituents of 
the blood-plasma. It is found very 
frequently on opening an abscess that 
no organisms can be seen, those that 
were originally present appearing to 
have undergone degenerative changes 
and to have been taken up by the phag¬ 
ocytes, or devouring cells. 

The process includes, according to 
Sajous, participation of the proteolytic 
or peptonizing action of enzymes in the 
serum supplied in large quantities to 
the abscess. The prevailing view is 
that these are produced by the pyogenic 
bacteria. From his viewpoint (see 
“Internal Secretions,” vol. ii, 4th ed., 
1911, p. 907) these ferments are se¬ 
creted (though originally derived from 
the pancreas, thyroid, and adrenals) by 
phagocytes (Metchnikoff’s trypsic cy- 
tase), themselves and their liquefying 
action has for its purpose to destroy 
the bacteria and their toxins in the ab¬ 
scess. The pathogenic organisms are 
first sensitized and softened by opso- 


200 


ABSCESS (WITHERSTINE). 


nins and agglutinins (thyroid secre¬ 
tion), and thus rendered vulnerable not 
only to the digestive action of the phag¬ 
ocytes when ingested by these cells, but 
to the ferments (trypsin mainly) they 
contribute to the abscess fluids, in which 
they accumulate in large numbers. 

Differential Diagnosis. — Fluctua¬ 
tion only indicating the presence of 
fluid, the presence of this sign without 
the other symptoms mentioned should 
inspire great circumspection, especially 
if surgical measures are employed. 

Aneurism is the most dangerous con¬ 
dition to fear. It has, however, a less 
acute history, a peculiar thrill and ex¬ 
pansile pulsation, and can only exist in 
close proximity to a large vessel. 

Certain semisolid growths may sim¬ 
ulate an abscess. When the possibility 
of an aneurism has been eliminated, a 
fine trocar or exploring needle, if care¬ 
fully used, will determine the diagnosis. 

Prognosis.—This depends upon the 
general health of the patient. In the 
robust a suppurative process usually 
reaches the stage of resolution without 
giving rise to complications. In indi¬ 
viduals weakened by disease, hereditary 
or acquired, an abscess may be pro¬ 
tracted and exhaustive, and diffusion is 
more likely to occur if resisting tissues 
interfere with the superficial evacuation 
of the pus. Deep abscesses are espe¬ 
cially prone to become protracted 
through this cause, the resistance of 
muscular aponeuroses, etc., forcing the 
pus into the cellular interstices. Fistu¬ 
lous tracts, or large suppurative areas, 
are thus created, and the patient may 
succumb to blood poisoning or its con¬ 
sequences. 

Treatment. — General Measures .— 
Rest and elevation of the affected 
region, if possible; salines, if purgation 
is necessary. Easily assimilable food. 


but not low diet; avoidance of stimu¬ 
lating beverages, alcohol, coffee, etc. 

Internal Remedies.—If the case Is 
seen early the suppuration can some¬ 
times be arrested by the use of one of 
the following agents, supplemented by 
one of the local applications: Tincture 
of aconite, 3 to 10 drops every hour, 
closely watching the patient’s pulse; 
tincture of veratrum viride, 1 drop 
every hour until the pulse becomes 
slower, the skin moist, and slight 
nausea occurs; or calcium sulphide 
(sulphurated lime), grain every 
hour; or, again. 

Sulphate of quinine, 1 grain. 

Ext, of nux vomica, % grain. 

For one pill, to be taken every three hours. 

Many incipient abscesses disappear 
under the internal use of the hypophos- 
phites of potassium, sodium, and cal¬ 
cium. They also act as an excellent 
prophylactic, if given before pus has 
formed. Tousey believes them to be 
more efficient than calcium sulphide. 
The combination used by Tousey is 5 
grains of calcium hypophosphite, and 2 
grains each of the sodium and potas¬ 
sium hypophosphites, administered in 
syrup or two capsules, followed by half 
a glassful of cold water. 

Fresh bre\vers’ yeast in doses- of 3j 
to 5ij in water or undiluted, just before 
or during meals, is a favorite remedy 
with many, although diarrhea some¬ 
times results, even when the yeast is 
fresh. A substitute preparation is made 
by macerating compressed yeast in 
water. Desiccated yeast is also used. 

In addition to these internal remedies, 
we should not forget that stimulation, 
nutrition and general hygienic measures 
are of considerable value. 

Thyroid gland in doses of 1 or 2 
grains three times daily hastens the 
disappearance of abscesses, by increas- 


ABSCESS (WITHERSTINE). 


201 


ing the proportion of opsonins in the 
blood (Sajous). 

Ferges and Gergo recommend the 
use of fresh normal blood-serum from 
the horse or from cattle in the local 
treatment of acute suppurative proc¬ 
esses in 100 cases. The pus was first 
aspirated, serum next injected to rinse 
out the cavity, using a needle closed 
at the end, but with a row of openings 
just above it; then the excess of fluid 
aspirated, and the opening covered 
with a bit of sterile gauze held by ad¬ 
hesive. It is important that all the 
excess of serum be removed from the 
cavity ; otherwise, symptoms of serum 
intoxication may follow. The serum 
apparently produces both a passive 
and an active immunity, stimulating 
leucocytosis and phagocytosis. Bet¬ 
ter healing can be obtained by this 
method, according to the authors, than 
in any other way. Acute abscesses 
in the soft parts, whatever be the 
micro-organism present, show espe¬ 
cially good results. One treatment 
with the serum generally suffices. 

External Remedies.—The surface is 
carefully cleansed with antiseptic soap 
and sprayed with a 2 per cent, carbolic 
acid solution, or with hydrogen per¬ 
oxide, every two hours, the atomizer 
being used for ten minutes at each sit¬ 
ting. (Verneuil.) 

Compresses dipped in hot 1:4000 
corrosive sublimate solution are very 
efYective. If abscess is upon an ex¬ 
tremity, a 1: 4000 corrosive sublimate 
solution may be employed as a bath 
for the limb, the latter being left in 
the solution several hours at a time. 

A solution of nitrate of silver (30 
grains to the ounce) may be applied 
frequently with a camel’s hair pencil. 

Tincture of iodine may be applied in 
the same manner every three hours. 


When the surface becomes very 
tender, belladonna ointment may be 
rubbed in every two hours. 

In abscesses characterized by very 
severe pain a 10 per cent, solution of 
cocaine may be introduced by cata- 
phoresis, the anode sponge of a gal¬ 
vanic battery being applied to the part. 
The sittings should last five minutes, 
and be repeated every three hours, the 
current not exceeding 5 milliamperes. 
During the intervals warm fomenta¬ 
tions—with borated, camphorated, or 
pure water—are of great value. 

Encouraging results obtained in the 
treatment of tendon-sheath phlegmons 
and suppurating inflammation in gen¬ 
eral with superheated air, applied with 
an ordinary apparatus. It is used twice 
a day for two or three hours each time, 
maintaining a temperature of from 90° 
to 110° C. (194° to 230° F.) within 
the frame at half its height. Thus ar¬ 
ranged, the temperature on the skin 
averaged 44° or 47° C. (111° or 116° 
F.), and the acceleration and sweating 
induced seemed to keep the temperature 
of the skin within due bounds. The ap¬ 
plications of the hot air are made the 
day after the abscess has been incised 
and evacuated, and the cavity packed 
with iodoform gauze. He also states 
that neglected injuries of the fingers 
which would otherwise have necessi¬ 
tated amputation healed under this 
hot-air treatment without requiring 
operative measures, and recovery was 
hastened. This treatment also caused 
an abolition of pain. (Zentralblatt fiir 
Chir., Oct. 24, 1908.) 

Pads of gauze wrung out of hot boric 
acid solution (an ounce to a quart of 
water), applied as hot as the patient 
can bear them, and well covered with 
oiled silk to keep in the heat and mois¬ 
ture, are the best; wherever applicable, 
as with the hands or feet, the inflamed 
part should preferably be submerged 
every hour for a period of five to ten 
minutes in the hot boric solution itself. 


202 


ABSCESS (WITHERSTINE). 


The application of a sheet of zinc, 
the thinnest possible, cut to fit the 
shape of the lesion and applied di¬ 
rectly to it, was found exceptionally 
effectual by the writer, who attrib¬ 
utes the results to the ions gener¬ 
ated by the different nascent com¬ 
pounds of zinc. The metal is held in 
place with a dressing which is left 
undisturbed for 5 or 7 days. Any 
tendency to hypertrophy of the 
edges of the lesion calls for cauteri¬ 
zation. Long rebellious cold ab¬ 
scesses yielded promptly to this 
measure. C. H. Sztark (Arch, de 
Med. des Enfants, Oct., 1918). 

Wright’s Bacterial Vaccines.— 
Treatment of staphylococcus and strep¬ 
tococcus infections (abscess, suppura¬ 
tion, etc.) by the therapeutic inoculation 
of staphylococcus and streptococcus 
vaccines, as suggested and developed by 
Sir A. E. Wright, of London, has 
found many endorsers. A bacterial 
vaccine is a sterilized, standardized 
emulsion of the infecting micro-organ¬ 
ism. It is made by scraping the film of 
a recent agar culture into a 1 per cent, 
salt solution, sterilizing at 60° C. (140° 
F.), and subsequently standardizing to 
a given number of micro-organisms per 
cubic centimeter. The method is, how¬ 
ever, a new and complex one, and, until 
its use has been more thoroughly ex¬ 
plored, it should only be employed 
under the guidance of an expert. 
Whether an opsonic control of the in¬ 
jections will always be necessary still 
remains to be shown, but in all cases 
the use of the vaccines should be pre¬ 
ceded by a most careful bacteriological 
examination, and the particular vaccine 
should be prepared for each individual 
patient. The dose of staphylococcus 
vaccine is 100 to 1000 millions; an 
inoculation being made every ten days. 
The dose of streptococcus vaccine 
which is more toxic than staphylococ¬ 


cus is 20 to 60 millions; the inoculations 
being repeated weekly or every two or 
three weeks. 

Case of furunculosis, subperiosteal 
abscess of the head, and necrosis of 
the bones of the skull treated by oper¬ 
ation and autogenous vaccine. Staphy¬ 
lococcus aureus was recovered from the 
parietal abscess and from the blood. 
An autogenous vaccine was made, and 
4 doses were given at intervals of four 
days. The first dose was 50,000,000, 
the second 100,000,000, and the last 2 
150,000,000. With no constitutional re¬ 
action, the local condition rapidly im¬ 
proved. The general condition of the 
patient improved, but a portion of the 
bone at the base of the abscess was 
denuded and necrosed. At a later date 
this sequestrum was removed and the 
patient was given 3 more injections of 
the autogenous vaccine at four days* 
interval, each dose being 150,000,000. 
Within three weeks the patient was in 
normal condition. The author urges 
preference for the autogenous vaccine. 
G. G. Ross (Monthly Cyclo. and Med. 
Bull., Sept., 1910). 

Bier’s hyperemic treatment (passive 
congestion or artificial hyperemia) of 
acute abscesses has given excellent 
results as to immediate relief of pain 
and reduction of inflammation. 

Inflammation, according to Bier, does 
not in itself represent a diseased condi¬ 
tion, but is a phenomenon indicating 
the body’s attempt to resist a deleterious 
invasion. To increase this beneficent 
inflammatory hyperemia resulting from 
the fight of the living body against in¬ 
vasion, is the aim of Bier’s hyperemic 
treatment. The blood must, however, 
continue to circulate; there must never 
be a stasis of the blood. Bier’s method 
artificially increases the redness, heat, 
and swelling, three of the four symp¬ 
toms of acute inflammation. He dis¬ 
cards all means that tend to subdue 
inflammation. 

Bier produces this hyperemia by any 


ABSCESS (WITHERSTINE). 


203 


or all of three methods: Elastic band¬ 
age or band, cupping glasses, and hot 
air. In the use of the elastic bandage, 
it should cause slight obstruction to the 
return of the blood, but not sufficiently 
firm as to obliterate the pulse beat 
below or be in the least way annoyable 
to the patient. 

The technique is correct if there is 
absolutely no increase of pain, and if 
there is visible hyperemia of the parts 
subjected to treatment; the portion 
distal to the bandage must appear bluish 
or bluish red—never white. All dress¬ 
ings should be removed while the com¬ 
pressing elastic bandage is in place, the 
wounds or bruises being covered with 
sterile gauze kept in place by a loosely 
applied towel. Under hyperemic treat¬ 
ment any abscess must be opened and 
l)us evacuated. 

Acute inflammatory processes require 
application of the hyperemic treatment 
for twenty to twenty-four hours per 
day. In chronic cases, especially if 
tuberculous, shorter sittings, from two 
to four hours per day. 

In the use of suction apparatus or 
cupping glasses to produce obstructive 
hyperemia, the skin should turn red or 
bluish red, but never white; circulation 
must not be interrupted. The vacuum 
apparatus of large size is supplied 
with a suction pump. These suction 
glasses are applied for five minutes, six 
times daily, with intervals of three 
minutes between applications, in .order 
to give the edema and hyperemic swell¬ 
ing an opportunity to disappear. Thus 
the entire time of treatment is three- 
quarters of an hour each day. 

Treatment of acute abscess by passive 
congestion has given excellent results. 
Cases of purulent arthritis, suppuration 
of tendon sheaths, and acute abscesses 
and carbuncles have shown without ex¬ 
ception almost immediate relief of pain 


and reduction of inflammation. The ab¬ 
scess either became “cold” or its con¬ 
tents changed to serum or were re¬ 
sorbed. Purulent arthritis was treated 
with passive motion after all pain had 
been relieved, ffihe writer selected 15 
of the 110 cases cited for brief descrip¬ 
tion in the article. All cases were 
quickly cured, and it was only rarely 
necessary to open the abscess. Of the 
15 cases reported, 8 were resolved, 3 
were opened, and 4 were discharging 
when admitted. Bier (Miinch. med. 
Woch., Jan. 31, 1905). 

By means of artificial hyperemia we 
can often abort an infective process and 
save the breaking down of tissue, or, if 
at the beginning of treatment the proc¬ 
ess has gone on to the breaking down 
of tissues, the hyperemic method assists 
in quickening the process of expulsion 
of the products of infection and also 
the process of repair. J. H. Beaty 
(Jour. Minn. State Med. Assoc., Jan. 
15, 1908). 

In the use of hot air to produce 
hyperemia we produce an arterial 
hyperemia which differs from the ob¬ 
struction or venous hyperemia. The 
effect of hot-air hyperemia is also dif¬ 
ferent upon the body and also upon the 
pathologic process. This last method is 
apparently not used in the treatment of 
abscess. 

The author comments on the value 
of Wright’s solution of sodium chlo¬ 
ride, 4 per cent., and sodium citrate, 
1 per cent., as an agent for promot¬ 
ing drainage of abscesses. The hy¬ 
pertonic solution of sodium chloride 
by osmosis brings about a flow of 
lymph through the abscess walls, 
while the sodium citrate, by precipi¬ 
tating the calcium salts in the lymph, 
prevents the latter from clotting, and 
thus perpetuates the discharge. The 
lymph and 4 per cent, salt solution 
both antagonize the bacteria. 

The technique of treating an abscess 
by this plan is described as follows; 
The abscess is opened by a wound as 
small as will allow the cavity to be 
wiped out, or thoroughly emptied by 


204 


ABSCESS (WITHERSTINE). 


expression. The surrounding skin is 
well cleaned with 70 per cent, alcohol 
and smeared up to the very mouth 
of the wound with boric acid or euca¬ 
lyptus vaselin, in order to avoid skin 
irritation from the salt solution. If 
the skin tension closes the opening a 
bit of rubber dam may be put in. 
The wound is covered with a volumi¬ 
nous pad of gauze or of absorbent 
cotton covered with gauze, dripping 
wet with hot salt and citrate solu¬ 
tion. A many-tailed bandage or some 
other application holds the poultice 
in position, and the part is put at 
rest. Outside the dressing may be 
applied a hot flaxseed poultice or a 
hot-water bottle. In any case, as 
often as the dressing gets cold, more 
of the hot solution is poured orver the 
whole dressing to wet and warm it 
again, or the dressing is removed and 
the whole part soaked, if possible, or 
bathed with the same solution. 

The solution is contraindicated if 
there is a tendency to persistent ooz¬ 
ing of blood from the wound, and 
where the formation of protective 
adhesions is desirable. 

Inguinal and axillary bubo, abscess 
of neck, septic fingers, mastoid 
wounds, otitis media after paracen¬ 
tesis, all drain well under this method. 
The solution should be used only for 
the first thirty-six to seventy-two hours 
after operation, during the acute stage 
of inflammation. The wound is then 
filled with glycerin or balsam of Peru. 
Crandon (Annals of Surg., Oct., 1910). 

The iodoform bone-wax recom¬ 
mended by von Mosetig-Moorhof 
tried in 5 cases, in which the wax 
failed and was discharged. It is of 
value as a filling in selected cases 
of circumscribed abscess cavities in 
bone. Its use shortens the convales¬ 
cence and makes the dressings easy 
and painless. Simmons (Annals of 
Surg., Jan., 1911). 

Bismuth paste injection is an agree¬ 
able procedure, practically painless 
and free from risk, and of value in 
the treatment of chronic fistulae and 
abscess cavities. H. H. Schmid 
(Wiener klin. Woch., Nu. 7, 1911). 


The writer tried the effect of 
X-rays upon a case of chronic suppu¬ 
ration of very long duration, which 
had resisted other forms of treatment, 
including surgical operation. The 
suppuration was arrested, the part 
was healed, and the cure has lasted 
to the present time. Several other 
cases of a similar kind were then 
treated, and recovery obtained. Cum- 
berbatch (Lancet, May 16, 1914). 

In pyogenic infections the defen¬ 
sive tissue reaction awakened is 
purely local, general reactions being 
but slightly marked or absent. In 
order to be able to inject the germs 
in an absorbable form, the writer 
combines the Pasteur method of age¬ 
ing cultures with the modern pro¬ 
cedure of sterilization of cultures by 
heat. Much larger doses of the Del- 
bet vaccines—billions—of germs can 
thus be injected, without producing 
any “negative phase.” On the other 
hand, severe reactions similar to 
Widal’s “hemoclasic attacks” often 
result; though manifestations of tox¬ 
icity, these reactions are often a fa¬ 
vorable indication. In one case an 
injection of 20 billions of germs in 
a case of very grave phlegmon of 
the hand was followed even by dysp¬ 
nea, asphyxial attacks, and cyanosis; 
but within 24 hours the local condi¬ 
tion improved and recovery very rap¬ 
idly followed. Experience has shown 
that the best dose of the vaccine is 
4 C.C., containing about 13 billions of 
bacteria. The vaccine used is a stock 
preparation containing streptococci, 
staphylococci and pyocyaneus germs 
—the latter in large number, 8 bil¬ 
lions. The author does not believe 
in an essential specificity of vaccines; 
Wright has, himself, given up auto¬ 
genous vaccines, and has even ex¬ 
pressed a suspicion that vaccine pre¬ 
pared with a germ different from that 
causing an infection gives better clin¬ 
ical results. The pyocyaneus germ 
is chosen because it plays a useful 
role in relation to the streptococcus, 
hindering its development and attenu¬ 
ating its effects. In the last 6 years 
no case of carbuncle has been incised 


ABSCESS (WITHERSTINE). 


205 


in the writer’s service. Recovery 
from boils, lymphangitis, and erysipelas 
is rapid under the vaccine treatment. 
Lymphangitic abscesses are given com¬ 
bined incision and vaccine treatment. 
Once sterilization has been secured, 
the wound margins are brought to¬ 
gether with plaster strips to accelerate 
healing. Adenitis disappears in a few 
days under the treatment, or else 
softens very rapidly, so that after 
evacuation through an incision the 
parietes promptly come together 
again. This method is frequently in¬ 
dicated in abscesses of the wisdom 
teeth, in which the relative degree ot 
the glandular and the periosteal in¬ 
volvements is difficult to define. In 
subacute osteomyelitis, the procedure 
gave successful results in 3 out of 6 
cases. Good results were likewise 
obtained in acute salpingitis. Recently 
definite improvement was noted in 
cases of gonococcic arthritis, although 
specific serum had failed. Delbet 
(Presse med., Feb. 7, 1920). 

Antiferment Treatment.—This so- 
called “physiologic treatment” of abscess 
was introduced by. Muller and Peiser. 
It is based on the antagonistic action 
the proteolytic ferment derived from 
leucocytes is supposed to meet from 
an antiferment in the blood-serum, 
especially in morbid effusions. This 
antiferment can be obtained from the 
patient’s own blood-serum, after vene¬ 
section or from puncture fluids. The 
contents of the abscess being aspir¬ 
ated, the antiferment is then injected 
into the cavity with the same needle, 
enough being introduced to fill it 
without distending it. The contents 
of the abscess are then again removed 
and the cavity is once more filled with 
fresh antiferment. This is repeated 
the next day if the area is still sensi¬ 
tive, the antiferment being left in. 

The writer has tried the injection 
of leucofermantin into abscesses—a 
treatment based upon the fact that a 


proteolytic ferment is found in the 
polymorphonuclear leucocytes. A 
fairly large needle was used for 
aspiration and injection, and, after 
evacuating the abscess, he injected 
and withdrew a small quantity of 
serum, so as to clean out the cavity 
as thoroughly as possible before 
making the final injection, which was 
allowed to remain; a moist aseptic 
dressing was then applied. If the 
aspiration had to be repeated, the 
needle was inserted through the old 
puncture, so as to save pain. The 
quantity of serum left in varied, ac¬ 
cording to the size of the abscess, 
from 2 to 15 c.c. The author feels 
convinced that the principle on which 
the method is based is sound, and 
that it opens up a new pathway in 
the physiological treatment of sup¬ 
purative inflammation. MacEwan 
(British Medical Journal, Jan. 22, 

1910) . 

Antiferment serum exerts a slight 
degree of curative action upon sup¬ 
puration, but must be brought into 
intimate contact with the whole of 
the suppurating surface. It is suited 
only for superficial, well-defined ab¬ 
scesses. Boit (Med. Klinik, Apr. 16, 

1911) . 

Surgic.al Measures.—Incision and 
drainage tersely indicate the surgical 
treatment of acute abscess. If sup¬ 
puration cannot be avoided, the ab¬ 
scess should be opened under rigid 
asepsis, as soon as an adequate quan¬ 
tity of pus has formed to constitute 
an abscess sufficient in size to be 
recognized by the surgeon as such 
(Senn), or as soon as the presence of 
pus has been determined by the ex¬ 
ploring needle or syringe. An early 
incision prevents excessive loss of tis¬ 
sue, less deformity and leaves smaller 
scar. 

If a local anesthetic is necessary, 
one of the following may be used: 
Twenty drops of a 1 to 5 per cent, 
solution of cocaine introduced sub- 


206 


ABSCESS (WITHERSTINE). 


cutaneously near the abscess; ether 
sprayed over the seat of the abscess 
until local numbness is experienced; 
chloride of methyl or chloride of ethyl 
vapor. The latter is especially effica¬ 
cious; the parts turn white when 
ready,—generally in about two min¬ 
utes. Seltzer water spurted over the 
surface may be used to advantage 
when none of the other agents can be 
obtained. 

To open an ordinary abscess a 
single small incision suffices; but, if 
it is large, several small incisions 
should be made to render perfect 
evacuation of its contents possible by 
drainage. If the abscess is super¬ 
ficial, the skin alone should be cut, 
but if it is deep seated the skin 
and fascia should be incised and the 
grooved director, or the points of a 
pair of forceps, used to reach the pus, 
the opening being kept patent with 
forceps. The cavity is then thor¬ 
oughly emptied and syringed out with 
1: 10,000 corrosive sublimate solu¬ 
tion, or, better, with normal salt solu¬ 
tion or boric acid solution, until the 
fluid comes out perfectl}' clear. Pres¬ 
sure with the fingers is to be avoided, 
but loose necrotic tissue should be re¬ 
moved if it can be done without 
injury to surrounding structures. The 
incision and its surroundings are then 
carefully washed with one of the 
solutions mentioned, and an aseptic 
drainage-tube inserted. The wound 
is dusted with iodoform or dermatol, 
and an antiseptic dressing is applied, 
exerting slight pressure with bandage. 
If the abscess is deep, the drainage- 
tube should be shortened daily; if it is 
superficial, the drainage-tube can be 
withdrawn the second or third day. 

Drainage by means of rubber drain¬ 
age-tubes of sufficient size is preferred 


to the use of gauze. Two tubes 
placed side by side facilitate irrigation 
when necessary. 

The necessity for radical treatment 
of any local suppurative process 
which persists in spite of conserva¬ 
tive treatment is emphasized by the 
writer. 

Such a suppuration is in numerous 
instances a grave menace to the body. 

Tubular drainage should be used 
only when a suppurating cavity is to 
be drained, when it is impossible to 
make a large opening, or when the 
drain cannot be safely inserted at the 
lowest point. 

The introduction of gauze into 
a suppurating cavity insufficiently 
opened is a blind and dangerous 
procedure. 

The best method of determining 
how and where gauze should be 
inserted is to introduce a gloved 
finger. D. Taddei (Riforma med., 
xxxvi, 447, 1920). 

When it is necessary to traverse the 
peritoneal or pleural cavity in order 
to reach a collection of pus, infection 
may be avoided by carefully packing 
off the cavity with gauze, so as to 
form a sort of well with the abscess 
at the bottom. 

The kind of dressing used after the 
abscess has been opened will depend 
upon the condition of the parts. If 
there be much infiltration of the tis¬ 
sues, swelling, and pain, a hot, moist 
antiseptic dressing is to be applied, as 
it favors absorption and is at the same 
time soothing to the patient. Any 
weak antiseptic solution (barring car¬ 
bolic acid for fear of gangrene) may 
be used, as boric acid, bichloride of 
mercury (not stronger than 1 to 20,- 
000), or normal salt solution. The 
dressings (wet or dry) while suffi¬ 
ciently firm to favor collapse and 
adhesion of abscess walls should yet 


ABSCESS (WITHERSTINE). 


207 


be loose enough to permit of easy 
absorption and evaporation of dis¬ 
charges. 

COLD, OR TUBERCULOUS, 
ABSCESS.—Symptoms. —These ab¬ 
scesses frequently attain a large size, 
and last for months without their pres¬ 
ence being detected. Besides failing 
general health, the symptoms of the 
causative trouble are the only prom¬ 
inent ones. The spine, the hips, the 
genitourinary tract, and the lymphatic 
glands are the organs most prone to 
tuberculous disorders giving rise to 
cold abscesses. They sometimes ap¬ 
pear several months and even years 
after the beginning of the primary 
disease. 

The general symptoms of tuberculous 
abscesses do not closely resemble 
those of ordinary suppuration, but 
vary with the resisting powers of the 
individual. There is nearly always a 
slight evening rise in temperature 
(hectic) followed by a subnormal 
temperature in the morning. Loss of 
flesh and strength and the presence 
of anemia, more or less marked, are 
usual, although they may not occur 
unless mixed infection (tubercular 
and purulent) takes place. There is 
no leucocytosis. Amyloid (albumi¬ 
noid) degeneration may appear as a 
later phenomenon. 

The local symptoms are as a rule very 
slight, and are indicative of the effects 
of pressure upon organs or nerves 
rather than activity in the abscess 
itself. Large fluctuating abscesses 
may exist in various parts of the body, 
even about joints, without serious dis¬ 
comfort to the patient. No pain is 
experienced as a rule; cold abscesses 
are not even tender to the touch. 
There is no redness until the abscess 
is about to break, the focus of the 


liquid mass being otherwise too 
deeply seated, the skin covering the 
abscess remaining white or normal in 
color unless the abscess be just be¬ 
neath the surface, which phenomenon 
has caused the name “white swelling” 
to be applied in tuberculosis of the 
knee. 

The above symptoms usually follow 
or are coincident with the sudden 
appearance of a swelling. Though 
generally soft, it may be hard, and 
suggest a tumor in the vicinity of the 
spinal column (Pott’s disease), above 
or below Poupart’s ligament, after 
burrowing along the psoas muscle 
(psoas abscess), on the inner aspect 
of the thigh, or in the lumbar region 
(lumbar abscess), etc. In the neck 
cold abscesses are usually due to dis¬ 
ease of the neighboring cervical 
lymphatic glands. The skin either 
remains normal or gradually becomes 
thinned and softened until an external 
opening is formed. 

Fluctuation, usually detected with 
ease, is sometimes hidden by a thick 
investing layer of lymph, which gives 
the mass a peculiar tension, suggest¬ 
ing a lipoma or some other hard 
growth. Aneurisms sometimes con¬ 
vey the sensation produced by a cold 
abscess: a fact to be borne in mind 
when operative procedures are under 
consideration. 

Pathology.—A cold abscess can al¬ 
ways be traced to a specific inflam¬ 
matory process, and almost invariably 
to one of a tubercular nature. Where 
the confluent masses in the center of 
a nodule begin to break down, there 
is formed a collection of material sur¬ 
rounded by tuberculous tissue. This 
material becomes infiltrated with leu¬ 
cocytes, and thus is produced a cavity 
containing fluid fatty material, frag- 


208 


ABSCESS (WITHERSTINE). 


ments of cells, and leucocytes, around 
which there is granulation tissue filled 
with tubercles. In this way a tuber¬ 
culous abscess is formed. It seems at 
times to be quite a matter of accident 
whether the abscess breaks into the 
joint or finds its way by a more cir¬ 
cuitous route into the surrounding 
connective tissue. As the tubercu¬ 
lous masses spread, caseation takes 
place at different points in the wall, 
and the masses are discharged into 
the cavity of the abscess; but the 
spread of the abscess is effected gen¬ 
erally by what is termed “burrowing 
of pus.” This burrowing occurs in 
various directions, and large collec¬ 
tions of pus altogether out of propor¬ 
tion to the original lesion are formed, 
and are known, as cold abscesses. 

What has been called a chronic ab¬ 
scess is very often no abscess at all. 
In tubercular processes the product 
of tissue proliferation undergoes co¬ 
agulation necrosis, and disintegrates 
into a granular mass, which, when 
mixed with a sufficient quantity of 
serum, forms an emulsion that micro¬ 
scopically resembles pus, but under 
the microscope shows none of the 
histological elements which are found 
in true pus. An abscess can only be 
called such if it contains pus. A true 
chronic abscess can originate in a 
tubercular, actinomycotic, or syph¬ 
ilitic lesion, when the granulation 
tissue is secondarily infected by the 
localization of pus-microbes, which 
convert the embryonal cells into pus- 
corpuscles. 

Differential Diagnosis.—The con¬ 
comitant disorder usually makes a 
diagnosis easy in a case of cold ab¬ 
scess ; but occasionally the swelling is 
the only indication of ill health, and 
it is important to determine, under 


such circumstances, the nature of the 
pus. The macroscopical appearances 
of “laudable” pus and of “sanious” 
pus are frequently so similar that a 
de visu diagnosis is not justified. Bac¬ 
teriological examination of the con¬ 
tents of such abscesses will show con¬ 
clusively whether they are true pus- 
containing abscesses or whether or 
not they are pseudo-abscesses. If 
cultivations are made of their con¬ 
tents, pus-microbes will grow upon 
proper nutrient media if it be a true 
abscess, while from the contents of a 
pseudo-abscess only the microbes of 
the primary infection can be cul¬ 
tivated. The information obtained 
by the discovery of the essential 
cause can be confirmed by inoculation 
experiments. 

Prognosis.—The walls of cold ab¬ 
scesses are usually tense and tough, 
and are lined with cheesy tuberculous 
material. They do not tend to col¬ 
lapse, as is the case with acute absces¬ 
ses, and for that reason are healed 
with difficulty. When, however, the 
seat of the original trouble can be 
reached and successfully treated, the 
fluid in the parts of the abscess tract 
is absorbed, and the caseous matter 
undergoes calcification. This fortu¬ 
nate issue of the case is seldom met 
with, however, and the abscess usu¬ 
ally continues, the primary etiological 
factor acting as a drain for the dis¬ 
eased area. The prognosis, therefore, 
depends upon the result obtained in 
the treatment of the latter. 

Surgical Treatment. — Experience 
has shown that when such a cold, or 
tuberculous, abscess opens spontane¬ 
ously, or is incised in a careless way, 
profuse suppuration and hectic fever 
follow, with only too often a speedy 
fatal result from septic infection. 


ABSCESS (WITHERSTINE). 


209 


Unless the surroundings of the patient 
admit of carrying out the antiseptic 
treatment to its full and perfect ex¬ 
tent, a chronic abscess should not be 
evacuated by incision. It should be 
aspirated. 

Incision of a cold abscess dooms 
it to infection with all of the 
dire consequences from chronic 
sinuses through amyloid disease to 
death. Even retropharyngeal ab¬ 
scesses should be drained only 
through aspiration. In very chronic 
cold abscesses cure is not infre¬ 
quently possible as a result of re¬ 
peated puncture and complete aspira¬ 
tion with suction. E. A. Rich (N. W. 
Med., July, 1916). 

Our associate editor. Prof. Robert T. 
Morris, of New York, referring to tuber¬ 
culous glands of the neck (see also Ade¬ 
nitis, this Index), called attention two 
years ago to the fact that in the large 
number of cases treated by him in the 
New York Post-Graduate Hospital in re¬ 
cent years, he had only resorted to opera¬ 
tion those abscesses that were actually 
suppurating. All others were treated con¬ 
servatively to avoid general infection, in¬ 
cluding miliary tuberculosis. In a number 
of cases the use of the new high-pene¬ 
trating X-ray proved most effective. More 
recently he has added tuberculin to the 
other resources, and is convinced that 
when this method is applied in the right 
way and for a sufficient length of time it 
is one of our most important resources 
against tuberculosis of any kind. 

Evacuation of abscesses of tuber¬ 
culous nature by incision should 
never be done; aspiration and injec¬ 
tion of these abscesses is at the pres¬ 
ent time the preferable course to pur¬ 
sue. The injection fluid consists of: 


Olive oil . Siiss (75 c.c.). 

Ether . ^i-% (37 c.c.). 

Creosote . 3iss (6 c.c.). 

Guaiacol . gr. xv (1 Gm.). 

Iodoform . 3iiss (10 Gm.). 


Of this mixture, to 1 ounce (7j4 to 
30 c.c.) is injected, depending upon 
the age of the patient and the size 
of the abscess. The abscess is as¬ 


pirated and injected every 10 days 6 
times. For fistulas and sinuses the 
following paste is used: 

Camphorated phenol, 

Camphorated naph- 
thol, of each .... 5iss (45 c.c.). 


Guaiacol . 3iiiss (105 c.c.). 

Iodoform . 5v (20 Gm.). 

Creosote . 3ij (8 c.c.). 

Lanolin, 


Spermaceti, of each. 3xiij (50 Gm.). 

The sinuses are injected every 
seventh day and a large sized urethral 
glass syringe is used. The sinuses 
communicating are held closed until 
the paste is solidified. C. W. Delany 
(Penna. Med. Jour., July, 1917). 

On general principles, necrosed or 
detached bone should be looked for in 
all cases. Strict antiseptic precautions 
are imperative to avoid mixed infection 
(bacilli of tuberculosis and pyogenic 
cocci). Preliminary precautions should 
be taken to meet violent hemorrhage 
due to va.scular erosion. 

When there is local inflammation and 
spontaneous opening of the abscess is 
probable, there should be a free inci¬ 
sion, a thorough scraping of its walls 
with Volkmann’s curette to transform 
the suppurating surfaces into bleeding 
ones. The cavity is then cleansed with 
a 5 per cent, solution of carbolic acid, a 
long drain is applied, and the wound is 
stitched as far as the drain. An anti¬ 
septic dressing is then applied. (Volk- 
mann, Trelat, Pozzi.) 

After opening the abscess the cavity 
may be washed out with peroxide of 
hydrogen in 10 per cent, solution or 
packed with iodoform gauze. Removal 
of the limiting sac is then performed 
by decortication, the steps being: free 
incision, the sac detached with finger 
or spatula and removal, and the cavity 
closed immediately. (Lannelongue.) 

The removal of the limiting sac is 
facilitated by filling the wound with 










210 


ACETANILIDE (SAJOUS). 


paraffin; the mass can then be removed 
as if it were a lipoma. (Cazin.) 

A psoas abscess should be opened in 
the loin and groin when possible. In 
the loin the incision should be made 
through the external and internal ob¬ 
lique, transversalis, and lumbar fascia, 
along the outer edge of the erector spine 
to the edge of the quadratus lumborum. 
The latter muscle and the transversalis 
fascia are divided on a level with the 
tip of the second or third lumbar trans¬ 
verse process, avoiding the lumbar ar¬ 
teries. The sheath and the psoas are 
then perforated with the finger or a 
trocar. A counteropening is then made 
below Poupart’s ligament to form a 
tunnel, into which a large-size drainage- 
tube is inserted. This is replaced, later 
on, by a tube at each end to obtain oblit¬ 
eration, beginning from the center of 
the canal. If one incision is preferred 
the loin should be selected. 

Aspiration and Injections. — When 
no local inflammation indicates that the 
abscess is soon to open, the fluid may 
be withdrawn with a large aspirator; a 
5 per cent, solution of carbolic acid is 
injected and then aspirated. This pro¬ 
cedure is renewed until the solution 
withdrawn is perfectly clear. A Lister 
bandage is then applied, insuring slight 
pressure. Five days later the treatment 
is renewed. About five sittings are re¬ 
quired. 

Injection fluids: Iodoform, 1 part; 
ether, 5 parts; distilled water, 5 parts. 
Injection not to be renewed while iodo¬ 
form is being excreted in the urine. 

Less painful is a mixture of 1 part of 
iodoform to 10 of glycerin (Billroth) 
or of olive oil (Bruns). 

Intoxication may be prevented by 
sterilizing the iodoform and excipient 
(except ether) by heating at 212° F. 
separately. 


Boric acid, a 4 per cent, solution, may 
be used as above (Menard), or naph- 
thol and camphor, 1 part each. About 
thirty sittings are usually required. 

The lesion being a tuberculous one, 
the general system should be treated ac¬ 
cordingly. Nutritious food, including 
a free supply of milk and eggs, pure 
air, sunlight, and sea-air, if possible, 
are indicated, as well as tonics and 
alteratives (codliver oil and hypo- 
phosphites, iodine, iodides, arsenic, 
quinine, strychnine, etc.). 

C. Sumner Witherstine, 

Philadelphia. 

A. C. E. MIXTURE. See Chloro¬ 
form. 

ACETANILIDE. — Acetanilidum, 
formerly known under the name of 
antifebrine, is obtained by boiling 
aniline with glacial acetic acid. It is 
the monacetyl derivative [CeHs.NH.- 
CH 3 CO] of aniline. 

PROPERTIES. — Acetanilide oc¬ 
curs as a white or colorless shining 
powder or as crystalline laminae. It 
is odorless, but has a slightly burning 
and bitter taste. 

DOSE. —The dose of acetanilide is 
3 to 5 grains (0.2 to 0.325 Gm.) in 
adults; the tendency, however, is to 
employ smaller quantities. In chil¬ 
dren, according to Griffith, the coal- 
tar products of this class are well 
borne; ^ to >4 grain (0.016 to 

0.033 Gm.) may be given at 6 months, 
increasing the dose by ^ grain with 
each year, until the adult dose is 
reached. The action of acetanilide 
should be closely watched in weak 
subjects and in hysterical women. 

Out of 274 observers who stated that 
they used acetanilide, 17, or 6.2 per cent., 
employed less than 2 grains as a mini¬ 
mum dose for adults; 113, or 41.2 per 
cent., employed 2.5 grains or less as a 


ACETANILIDE (SAJOUS). 


211 


minimum dose, and 155, or 56.5 per 
cent., employed from 3 to 5 grains as 
a minimum dose. Two hundred and 
forty, or a little over 87.5 per cent., 
never exceeded a dose of 5 grains, and 
34, or not quite 12.5 per cent., employed 
doses exceeding 5 grains. 

An examination of a number of pre¬ 
scriptions for adults on file in vari¬ 
ous pharmacies in Washington, D. C., 
brought into court as evidence, showed 
the average dose of acetanilide pre¬ 
scribed was 2.43 grains. Kebler, Mor¬ 
gan and Rupp (U. S. Dept, of Agricul., 
Bureau of Chemistry, Bulletin No. 126, 
July 3, 1909). 

MODES OF ADMINISTRA¬ 
TION. —Acetanilide is insoluble in 
glycerin, slightly soluble in water (1 
grain in 3 fluidrams of cold, and 1 
grain in 18 minims of hot, water), 
but completely so in alcohol (1 
grain in 23/2 minims), and readily in 
ether (1 grain in 18 minims). It is 
readily suspended in syrupy mixtures 
and can be given with most drugs 
thus administered. Acetanilide is 
also dispensed by druggists in the 
form of tablets, which are quite taste¬ 
less when taken with a mouthful 
of water. It may be given in the 
form of powders or in dilute alcoholic 
solutions. 

There was also formerly official the 
compound acetanilide powder {pul- 
vis acetanilidi compositus), contain¬ 
ing acetanilide, 7 parts; caffeine, 1 
part, and sodium bicarbonate (to in¬ 
crease the solubility of the acetani¬ 
lide), 2 parts, the dose of which is 5 
to 10 grains (0.3 to 0.6 Gm.). 

While acetanilide is not soluble and 
is readily suspended in syrupy mixtures, 
it can be combined with ammonia in 
any of its forms, salicylic acid, nux 
vomica, digitalis, codeine, creosote, po¬ 
tassium bromide, etc. A prescription 
can therefore be elaborated that can 
be much more accurately adapted to the 
case in hand than any of the ready¬ 


made combinations. The foundation of 
most of the coal-tar product combina¬ 
tions is acetanilide, which has been com¬ 
bined with bicarbonate of soda, caffeine, 
carbonate of ammonia, etc. The com¬ 
bination may be chemical or mechanical, 
it matters little which, as it is practically 
broken up in the body into acetanilide 
radicals and other constituents. L. Fau- 
geres Bishop (Med. News, June 10, 
1899). 

Various combinations of acetanilide 
with other drugs (adjuvants and corri- 
gents) may be made to meet the exi¬ 
gencies of practice, some of which are 
as follows:— 

Acetanilidi . gr. xij (0.800). 

Caffeince citratce _gr. iij (0.200). 

Camphorce mono- 
brom .gr. vj (0.400). 

Misce et fiant capsulae no. vj. 

Note.— The caffeine and camphor are 
used as corrigents to the acetanilide. 

Acetanilidi . gr. xv (1.000). 

Sodii bicarbonatis .. gr. x (0.650). 

Ammonii carbonatis. gr. xv (1.000). 

Misce et fiant capsulae (not pulveres) 
no. X. 

Note.— The sodium bicarbonate aids 
in the assimilation of the acetanilide, 
while the ammonium carbonate acts as 
a corrigent. 

3 Acetanilidi . gr. xx (1.300). 

Sodii bicarbonatis. gr. xv (1.000). 

Caffeince . gr. vj (0.400). 

Acidi citrici . gr. x (0.650). 

Misce et fiant capsulae (not pulveres) 
no. X. 

Note.— The caffeine and citric acid in 
the above should be mixed and slightly 
moistened; this allows the formation of 
a fresh preparation of citrated caffeine; 
it should then be dried and mixed with 
the other ingredients. 

B Acetanilidi . gr. xx (1.300). 

Sodii bicarbonatis. gr. xx (1.300). 

Sodii salicylatis . ^ss (6.000). 

Misce et fiant chartulae no. x. 

Note. —The sodium salicylate is used 
as a synergist to the acetanilide. 

Acetanilidi . gr. xx (1.300). 

Potassii bromidi . gr. xxx (2.000). 

Sacchari lactis .... gr. xv (1.000). 

Misce et fiant chartulae no. vj. 

Note. — The potassium bromide is 
used as a synergist to the acetanilide. 










212 


ACETANILIDE (SAJOUS). 


IJ. Acetanilidi . gr. xxv (1.600). 

Potassii bromidi . gr. xv (1.000). 
Caffeines citrate . gr. v (0.325). 
Misce et fiant capsulae no. x. 

Acetanilidi .. gr. xxv (1.600). 

Sodii bicarbonatis. gr. x^ (0.650). 
Caffeine citrates . gr. vj (0.400). 
Camphores mono- 

bromatee . gr. vj (0.400). 

Misce et fiant capsule no. x. 

Acetanilidi . gr. x (0.650). 

Sodii bromidi _ gr. l (3.250). 

Extracti hyoscy- 

ami . gr. v (0.325). 

Caffeines citrates . gr. v (0.325). 

Morphines sniphatis. gr. % (0.013). 

Misce et fiant tabellae (or capsiilse) 
no. X. 

Note.—T he sodium bromide, extract 
of hyoscyanius, and morphine sulphate 
all act as synergists to the acetanilide, 
while the caffeine corrects their action. 

Acetanilidi . gr. xx (1.300). 

Quinines snip hatis gr. xx (1.300). 

Extracti hyoscy- 

ami . gr. v (0.325). 

Extracti cannabis 

Ind . gr. iiss (0.163). 

Arseni trioxidi .. gr. 3io (0.0065). 

Strychnines stil- 

phatis .. gr. 14 (0.013). 

Misce et fiant tabellae (or capsulae) 
no. X. 

Note.—T he strychnine sulphate is 
used instead of the caffeine as a cor- 
rigent. 

Acetanilidi . 3j (4.000). 

Zinci oxidi . 3j (4.000). 

Amyli .q. s. ad Sj (32.000). 

Misce et fiat pulvis. 

Sig.; Use as a dusting powder. 

Acetanilidi . 5j (4.000). 

Adipis lan<s . 3ij (8.000). 

Petrolati ..q. s. ad Sj (32.000). 

Misce et fiat unguentum. 

B Antipyrines .3j (4.000). 

Caffeines citrates .. gr. xx (1.300). 
Aques destillates . iSiv (120.000). 
Misce et fiat solutio. 

Sig.: Teaspoonful as required. 

Note.—I n the above prescription anti¬ 
pyrin is used, as it is very soluble, while 
acetanilide is almost insoluble. W. H. 
Foreman and J. H. Gertler (Jour. In¬ 
diana State Med. Assoc., June 15, 1909). 

It has been supposed that the addi¬ 
tion of caffeine to acetanilide decreased 


its toxicity, and, therefore, the likeli¬ 
hood of untoward effects. Hale has 
shown experimentally, however, that 
such was not the case, and, indeed, that 
it greatly increased it. Sodium bicar¬ 
bonate, on the other hand, tends to les¬ 
sen the toxic effects of acetanilide upon 
the heart. 

By experiments on the hearts of 
warm- and cold- blooded animals the 
writer found caffeine of little or no 
benefit in acetanilide poisoning in so far 
as the cardiac energy and the blood- 
pressure were concerned, and that it 
apparently exerts a harmful effect in 
some cases. But there appeared, espe¬ 
cially in the dog, to be a well-established 
antagonism on the heart rate which, 
however, would probably be insufficient 
to be of any value in cases of poisoning 
in man. Feeding experiments demon¬ 
strated the absence of antagonism be¬ 
tween acetanilide and caffeine, in all 
cases the addition of the latter drug 
causing death more quickly or with a 
smaller dose. This, in connection with 
the imperfect antagonism- to the heart 
action, makes the use of caffeine in 
acetanilide mixtures especially question¬ 
able. Sodium bicarbonate, in contrast, 
lessens the toxicity of acetanilide, both 
in its action on the heart and on the 
intact animal, increasing the duration 
of life or making the use of a larger 
dose of acetanilide necessary to cause 
death. Hale (Jour, of Pharmacol, and 
Exper. Therap., Aug., 1909). 

INCOMPATIBLES. — Acetanilide 
forms insoluble compounds with the 
bromides and iodides in aqueous solu¬ 
tion, and a soft mass on trituration 
with chloral, carbolic acid, thymol, or 
resorcinol. According to Blackwood, 
unexpected and often alarming effects 
are observed when calomel is given 
with any coal-tar product. 

CONTRAINDICATIONS. — Ace¬ 
tanilide should not be used when the 
heart is fatty, weak, or enlarged; in 
blood disorders such as pernicious 
















ACETANILIDE (SAJOUS). 


213 


anaemia characterized by cell destruc¬ 
tion ; in phthisis or other exhausting 
diseases, and in pregnant or nursing 
women. 

PHYSIOLOGICAL ACTION.— 
As Antipyretic.—In the normal sub¬ 
ject, the temperature, according to 
Nothnagel and Rossbach and most 
authorities, is lowered only when 
toxic doses are given. Not so, how¬ 
ever, when fever is present. Here a 
small dose suffices to produce a 
marked fall. Dujardin-Beaumetz, for 
example, witnessed a decline of 3° C. 
(5.4° F.) and cyanosis in a case of 
typhoid fever in which grains 

(0.5 Gm.) had been administered. 
Manquat states that to 3 grains 
(0.1 to 0.2 Gm.) suffice to influence 
the temperature, acetanilide, accord¬ 
ing to Krieger, Cahn and Hepp, being 
far more active in this particular than 
antipyrine. Sweating and chills are 
occasionally observed. 

The investigations of Hare and 
Evans suggested that the fall of tem¬ 
perature produced in febrile cases was 
due to a decreased heat-production 
and increased heat-dissipation. But 
Wood, having found that the rectal 
temperature not only did not fall as 
did that of the surface, but that it 
rose, concludes that the experiments 
of Hare and Evans “cannot be used to 
explain how antifebrin reduces the 
temperature.” Moreover, most Euro¬ 
pean investigators, Lepine, Podanow- 
sky and others, hold that acetanilide 
acts by depressing the heat-center. 
According to Cushny, it affects the 
nervous heat-regulating mechanism 
in such a manner as to lower the level 
at which the body-temperature is 
maintained, the loss of heat necessary 
to produce the fall in temperature be¬ 
ing accomplished by dilatation of the 


cutaneous vessels. The manner in 
which acetanilide acts as an anti¬ 
pyretic is stated by Butler to be far 
from understood. 

Action as Analgesic.—According to 
the prevailing view, acetanilide acts 
directly as a sedative upon the nerv¬ 
ous system, especially upon the sen¬ 
sory portion of the spinal cord; with 
toxic doses the effect may extend to 
total loss of reflex action and sensory 
and motor paralysis, the muscles be¬ 
ing influenced only directly. Wood 
holds that, “directly or indirectly, ace¬ 
tanilide affects the cerebral function,” 
though at a certain stage of its toxic 
action consciousness may be uninflu¬ 
enced while the rest of the nervous 
system is clearly affected. Bokai 
ascribes the effects of acetanilide to 
paralysis of the motor nerve-endings 
in the muscles, sufficiently prolonged 
exposure of the latter to the poison 
also annulling their ability to con¬ 
tract. Cushny, referring to this and 
other coal-tar products, states that 
“by many they are supposed to have 
a sedative or depressant effect on 
the nervous system.” The analgesic 
action of acetanilide is generally as¬ 
cribed to this supposed sedative 
effect, though all agree that applied 
locally to the tissues it acts as a stimu¬ 
lant or mild irritant. Its toxic effects, 
however, should not be overlooked. 

Action on the Blood.—The cyanosis 
produced by excessive doses of ace¬ 
tanilide is ascribed by Lepine, He- 
nocque and others to transformation 
of the hemoglobin into methemoglo- 
bin, and by Vierordt, Halliday and 
others to the reduced haemoglobin as 
it occurs in venous blood. Some con¬ 
tend that the red corpuscles are dis¬ 
organized, while others hold that they 
remain intact. 


214 


ACETANILIDE (SAJOUS). 


Acetanilide, antipyrin, and acetphe- 
netidin lower the total amount of 
oxygen in the circulating arterial 
blood. The diminution is slight with 
antipyrin, which, in fact, in large and 
medium-sized doses causes at first an 
increase. With the other two agents 
the decrease is both pronounced and 
constant. The variations in the 
amount of carbon dioxide in the 
blood are not parallel with those in 
the oxygen. The respiratory func¬ 
tional capacity of the blood and the 
respiratory interchanges are dimin¬ 
ished. Piccinini (Arch. Inter, de 
Pharm. et de Therap., vol. xxii. Nos. 
1 and 2, Cyclo. Suppl., 1918). 

Action on the Circulation. —Injec¬ 
tions of acetanilide in animals have 
been found to cause at first a slight 
increase in the number and force of 
the heart-beats, with corresponding 
rise of blood-pressure. Later, and 
also from the first with larger doses, 
circulatory depression is observed. 
In febrile patients the lowering of 
temperature produced by the drug is 
often accompanied by reduction in 
the frequency and size of the pulse. 
Large doses are said to depress the 
heart directly. 

[These phenomena are the normal results 
of the exciting action of the drug upon the 
sympathetic center and the resulting con¬ 
striction of the arterioles. Those of the 
heart admitting less blood into its muscular 
walls, the force of its contractions and 
their number are reduced. The heart’s 
action may be arrested by the same process 
C. E. DE M. S.] 

UNTOWARD EFFECTS AND 
ACUTE POISONING. —The symp¬ 
toms of poisoning include primarily 
the cyanosis, which begins at the lips 
and then extends, gradually becoming 
more intense, over the face and the 
rest of the body, and is accompanied 
by profuse sweating and prostration. 
In some cases there is ashen lividity 
and the temperature falls rapidly to 


95° F. or lower. The pupils are 
dilated and fixed. The respiration is 
slow and shallow, and the pulse be¬ 
comes steadily weaker and then irreg¬ 
ular and fluttering. Somnolence, un¬ 
consciousness and coma, and cardiac 
arrest follow. In some instances 
sudden heart-failure occurs soon after 
the onset of the symptoms, the organ 
being arrested in diastole. Erythem¬ 
atous or urticarial skin eruptions 
and disorders of hearing are occasion¬ 
ally observed. 

An instructive case was published by 
Ballou some years ago. The patient was 
a man, aged 45, suffering from a form of 
intermittent fever. He complained of al¬ 
most unbearable headache;, pulse, 120; 
respirations, 23; temperature, 104.8° F. 
Ten grains of acetanilide were given, and 
about 20 minutes later the patient said 
his headache was relieved, and that he felt 
easier. About 45 minutes after the drug 
was administered all sweating ceased, and 
a peculiar sensation of warmth under the 
skin was complained of. To this, in 12 or 
15 minutes, was added intense itching, 
while in 3 or 4 minutes the whole body 
presented a general erythematous condi¬ 
tion. The entire surface was of a brighter 
red than that of a typical case of scarlet 
fever, and, like the scarlatina rash, it dis¬ 
appeared on pressure, to return as soon 
as pressure was removed. No part of the 
body was exempt from this rash, the con- 
junctivae, palms of the hands and soles of 
the feet being as red as any part of the 
body. The temperature of the surface 
seemed elevated, but the thermometer in 
the mouth showed that it was gradually 
falling. The body appeared as if every 
superficial capillary was dilated. 

With the appearance of the rash the 
itching became more intense, the patient 
assuming all positions possible while 
scratching. Within the external ear the 
itching was especially intense, but there 
was no disturbance of hearing. The rash 
lasted for 6 hours, without any apparent 
change, and then disappeared rapidly from 
all parts of the body simultaneously, and 
as the rash faded the itching subsided. 


ACETANILIDE (SAJOUS). 


215 


About this time a slight cardiac irregular¬ 
ity became evident, and this lasted for 4 
days. The only drug taken before the 
acetanilide was calomel (about 5 grains). 

The 2 unusual symptoms, intense itch¬ 
ing and general erythema, were due to ex¬ 
cessive dilatation of the arterioles after 
the true toxic effects had passed off, the 
violent excitation to which the poison had 
subjected the sympathetic center having 
temporarily exhausted it. Editors. 

According to the writer, study of 
the cases recorded in the literature 
and personal cases proves that the 
ingestion over a considerable period 
of time of acetanilide or related coal- 
tar products is productive of a defi¬ 
nite symptom-complex which is 
highly suggestive, if not absolutely 
diagnostic, of poisoning by this 
group. The subjective symptoms 
are; great general weakness, nervous 
excitability, insomnia, loss of appe¬ 
tite, digestive disturbances, palpita¬ 
tion, dyspnea, numbness and weak¬ 
ness of the extremities, pain in the 
region of the liver and spleen, and 
faint attacks. The chief objective 
symptom is cyanosis, which is often 
extreme, but usually fluctuating in in¬ 
tensity, accompanied by marked pal¬ 
lor of the mucous surfaces and with¬ 
out clubbing of the fingers. 

The blood-changes are quite char¬ 
acteristic, and due to the destructive 
action of a hemolytic poison circulat¬ 
ing in the blood-stream, which pro¬ 
duces a secondary anemia variable 
in degree. The erythrocytes are di¬ 
minished in number; they often pre¬ 
sent nucleated forms, show granular 
stippling, stain poorly, and are vari¬ 
able in size and form There is usu¬ 
ally a moderate leucocytosis of the 
polymorphonuclear variety, and there 
is often a relative increase of the 
lymphocytes. The appearance of the 
blood as it stands upon the finger¬ 
tip or the ear is very suggestive; it 
is either of a bluish-black color or 
chocolate in appearance. The col¬ 
oration of the plasma renders the 
estimation of the hemoglobin quite 
difficult. Gordinier (Monthly Cyclo. 
and Med. Bull., Mar., 1912). 


Out of 288 practitioners questioned, 
219, or 76 per cent., stated that they 
had observed instances of poisoning 
following the use of acetanilide. These 
219 observers report 614 cases of poison¬ 
ing, including 17 deaths, i.e., 2.7 per cent. 
The character of these cases and the 
doses used were as follows:— 

Pneumonia (child).. .One-half grain every 2 
hours until 2 grains 
were taken. 

Capillary bronchitis 


(child).Small doses frequently 

repeated. 

Capillary bronchitis 

(child).Small doses frequently 

repeated. 

Typhoid.Five grains every 4 hours 

Headache.About 20 grains. 

Headache.Thirty grains (?). 

Headache.“Orangeine” taken freely 

Headache.Thirteen or fourteen 5-grain 

doses in 12 hours. 

Headache.Bromoseltzer. 

Neuralgia.Dose not given. 

Neuralgia of heart...Five 5-grain doses in 5 
hours. 

Burn.Boroacetanilide applied 

freely. 

Burn (infant).Acetanilide applied freely 

to umbilical cord. 

Headache.Excessive doses of “bromo¬ 

seltzer.” 

Typhoid (child).Five grains. 

Typhoid (child).Dose not given. 

Malaria (child).One and one-half grains. 


Kebler, Morgan and Rupp (U. S. Dept, 
of Agricul., Bureau of Chemistry, Bul¬ 
letin No. 126, July 3, 1909). 

Experiments conducted by the 
writer to ascertain whether acetani¬ 
lide appeared in the milk of a nurs¬ 
ing mother, and, if so, whether in 
sufficient quantity to cause the death 
of an infant. They showed that 
acetanilide derivatives are at times 
eliminated, but that more frequently 
there is no trace of them in the 
maternal milk or the infant’s urine. 
The quantity found in each case was 
so minute that it could only be de¬ 
tected by holding the specimen 
against a white background. The 
time of the first appearance of the 
reaction after the administration of 
a dose of 4 grains varied from 7 to 
15 hours. Stevenson (Mich. State 
Med. Soc. Jour., Apr., 1914). 

The great majority of such cases 
are due to intoxication by proprietary 
headache powders sold under a vari- 

















216 


ACETANILIDE (SAJOUS). 


ety of fancy names. Proprietary prep¬ 
arations containing acetanilide were re¬ 
ported to have been used in 77, or 
12.5 per cent., of the 614 cases of 
poisoning mentioned above by Kebler, 
Morgan, and Rupp. It is well known 
that certain individuals show an 
idiosyncrasy to the drug, and in some 
instances very small doses will suffice 
to cause death. 

Many instances of “headache powder” 
victims have been published. Philip 
Brown, for instance, observed a case of 
fatal poisoning from this cause. The pa¬ 
tient, a man of 37, had taken six “head¬ 
ache powders” each containing 10 grains. 
He became delirious, complained of ab¬ 
dominal pain, vomited, and was slightly 
jaundiced. His temperature rose to 100.2° 
F. (37.9° C.), the lips and nails became in¬ 
tensely cyanotic, respirations shallow and 
frequent. The urine, of which 10 ounces 
were passed on admission, was nearly 
black and strongly alkaline. Anuria oc¬ 
curred, and 6 days later the man died. 
There was alternate constipation and 
diarrhea, and 48 hours before death the 
feces constantly showed blood-pigment, 
blood-clots, and corpuscles. 

Another case of acetanilide poisoning 
with fatal results following the ingestion 
of “bromoseltzer” taken to relieve a head¬ 
ache, was published by Hemenway. The 
heart, already weakened from repeated 
doses of the drug, was unable to stand 
a slight overdose and the victim died in a 
few hours. 

In a case of acetanilide poisoning, 
observed by Summers, in a woman, 
aged 26 years, who had taken 8 grains, 
there occurred collapse with strong 
convulsive movements, partial loss of 
consciousness, and great retching. 
Whisky, strychnine nitrate, and—for 
two hours—artificial respiration in¬ 
duced recovery. 

In another instance observed by 
Karps the patient had taken four 
headache powders. These had been 
taken each hour between nine and 


noon. The surface of the body pre¬ 
sented an ashen-gray appearance, the 
mucous membranes having a much 
darker hue. The temperature was 96 
degrees; pulse, 60, and respiration, 10. 
Digitalis, strychnine, and alcohol 
baths with friction were employed, 
with dry heat to the surface. When 
the patient was able to swallow, a 
combination of aromatic spirit of am¬ 
monia, brandy, and capsicum was 
given. Twenty-four hours later the 
temperature was slightly subnormal, 
the dusky appearance of the face dis¬ 
appeared to a large extent, but the 
symptoms of cyanosis did not wholly 
vanish until the second day. The 
powders contained 3 grains of acet¬ 
anilide, 2 grains of bicarbonate of 
sodium, and 1 grain of caffeine; hence 
the total dose was 12 grains of 
acetanilide. 

The doses capable of producing toxic 
effects are sometimes very small, but 
it is probable that some of the drugs 
recommended in textbooks for the 
treatment of poisoning by coal-tar 
products, strychnine and belladonna, 
for example, do more harm than good, 
and that small doses may thus prove 
fatal through the toxicity added to 
theirs by the supposed antidotes or 
remedial measures. 

When a large dose is taken, the 
symptoms once started may suddenly 
assume marked severity. 

Case in a man 52 years of age who 
suffered from severe chronic headache. 
Not obtaining relief from headache pills 
and powders he purchased an ounce of 
acetanilide in bulk and took a half-tea¬ 
spoon ful—about 30 grains. The head¬ 
ache disappeared in a short time, and he 
ffien went out on the street. While walk¬ 
ing he felt weak. He then went to a bar¬ 
ber shop, and the man who shaved him 
noted that he had a “terrible blueness.” 
He then entered a store, where in a 


ACETANILIDE (SAJOUS). 


217 


few minutes he was seen to sway and 
fall to the floor. He was found in deep 
syncope, extremely cyanotic, with a 
feeble and rapid pulse. He was readily 
resuscitated, but in a few minutes there 
was another attack of syncope, which 
was repeated a number of times during 
the next few hours. He gradually re¬ 
covered. J. B. Tyrrell (Jour. Amer. 
Med. Assoc., Mar. 31, 1906). 

Poisoning by Absorption.—Acetan¬ 
ilide having been recommended as a 
dressing for wounds, burns, and super¬ 
ficial injuries in general, many cases of 
poisoning have occurred owing to the 
large quantities applied to the lesions, 
and the ease with which it is absorbed. 

Two cases also emphasizing the neces¬ 
sity of caution even when using acetani¬ 
lide externally, were published by F. T. 
Stewart. The first case had sustained an 
extensive burn of the left lower extremity. 
The raw surface was covered with 
Thiersch’s skin grafts taken from the 
right leg and thigh. An assistant dressed 
the right limb. Early the next morning 
the patient became cyanotic, collapsed, 
and became unconscious. It was learned 
that the right leg had been copiously 
dusted with acetanilide. This drug has no 
place in aseptic cases, while in septic 
cases more efficient and less dangerous 
agents are available. 

Menasses observed 2 cases of acetan¬ 
ilide poisoning from absorption from ex¬ 
ternal wounds in children. The first pa¬ 
tient was a baby six weeks old who had 
a troublesome eczema of the buttocks. A 
powder was applied composed of equal 
parts of acetanilide and subgallate of bis¬ 
muth. Twenty-four hours later the skin 
of the child was markedly cyanotic, the 
temperature was subnormal, the respira¬ 
tions were feeble and shallow, the pupils 
were dilated, the heart was rapid and 
weak, and extremities cold. Hot applica¬ 
tions were ordered, with the internal ad¬ 
ministration of whisky, and at the end of 
three days all symptoms of poisoning had 
disappeared. 

The second case was that of a child of 
two and one-half years who had received 
a severe scald of the buttocks. A powder 


composed of equal parts of subnitrate of 
bismuth and acetanilide was applied, 
which soon relieved the pain. On the 
second day the lips, ears, and finger-tips 
were blue. The symptoms of prostration 
were present as in the first case, but not 
to the same degree. The blueness gradu¬ 
ally disappeared, and at the end of a 
week the wound was healed. 

Treatment of Acute Acetanilide 
Poisoning.—The physiological action 
of acetanilide being but imperfectly 
known, cases of intoxication by this 
drug are treated on general principles, 
i.e., by measures thought to counter¬ 
act the symptoms. Cardiac, respira¬ 
tory and vasomotor stimulants are 
therefore recommended. Ether, hy¬ 
podermically, has been most fre¬ 
quently used. Belladonna is regarded 
as the best drug to fulfill the indi¬ 
cations ; it tends to equalize the 
blood-pressure, especially when ex¬ 
ternal heat is applied simultaneously. 
Brandy, digitalis, strychnine, aro¬ 
matic spirits of ammonia and inhala¬ 
tions of oxygen have all been recom¬ 
mended. Artificial respiration is a 
valuable adjuvant to any treatment 
adopted. 

[In the light of my views, the toxic phe¬ 
nomena being all due to excitation of the 
sympathetic center, agents which depress 
this center are indicated. Amyl nitrite in¬ 
halations, sustained by nitroglycerin inter¬ 
nally or hypodermically, fulfill this role. 
Artificial respiration is important to insure 
prompt oxygenation of the blood as soon 
as the circulation is re-established. Warm 
(110° F.) saline solution intravenously, or, 
in less urgent cases, per rectum, facilitates 
excretion of the poison and prevents its 
irritating action on the sympathetic center, 
thereby hastening recovery. 

Contraindicated.— Digitalis, which, like 
acetanilide, though less actively, excites 
the sympathetic center, and alcohol, which, 
by becoming oxidized in the blood, favors 
its conversion into venous blood, and, 
therefore, cyanosis. Large doses of strych¬ 
nine, which, by causing excessive vasocon- 


218 


ACETANILIDE (SAJOUS). 


striction, tend to increase the constriction 
of the arterioles caused by the poison. 
C E. DE M. S.] 

CHRONIC ACETANILIDE POI¬ 
SONING. —The symptoms of this 
condition are: cyanosis, which may be 
extreme, anemia, and wasting. The 
anemia may be of sudden onset and is 
evidenced by a distinct leucocytosis, 
marked reduction in the hemoglobin 
percentage and in the number of red 
corpuscles, some of which show 
nuclei. Other common symptoms in¬ 
clude disordered digestion, enlarge¬ 
ment of the spleen without tender¬ 
ness, prostration, weak and frequent 
pulse, dyspnea, excitability, tremor, 
and mental aberration, with a tend¬ 
ency to deceive in denying the use of 
the drug. The urine is dark-colored. 
The combination of warm extremities 
with marked cyanosis is considered a 
distinguishing feature of poisoning by 
acetanilide. 

The blood changes above men¬ 
tioned may not T>e accompanied by 
marked impairment of health. Ex¬ 
periments in animals have shown that 
the prolonged use of acetanilide tends 
to cause fatty degeneration of the 
heart, liver, and kidneys. 

Case of a young woman who had 
persisted in taking some coal-tar 
product originally prescribed for 
migraine. About a year after her 
marriage she died suddenly following 
an apparently normal labor. The 
knowledge of the continued use of 
the prescription during pregnancy 
gave the clue to the cause of death. 
A great danger of chronic poisoning 
with coal-tar products is the sudden 
yielding of the heart to unusual 
strain. S. Solis-Cohen (Boston Med. 
and Surg. Jour., Feb. 22, 1906). 

Case of chronic acetanilide poison¬ 
ing. The patient had long used 
acetanilide, about a dozen 5-grain 
tablets in twelve hours. She pro¬ 


cured 1000 at a time, and in four 
years had used several thousand. She 
suffered from severe headaches and 
vomiting attacks lasting for two or 
three days, and, as a rule, she would 
have to be in bed. Two years earlier 
she began the use of morphine to¬ 
gether with the acetanilide and was 
using as much as 2 grains of mor¬ 
phine a day to get relief. When first 
seen, she had been in bed for six 
weeks, was emaciated, no appetite on 
account of persistent vomiting, head¬ 
ache always present; slightly jaun¬ 
diced, with marked tenderness and 
dullness over the gall-bladder region; 
very constipated, and suffering from 
tympanites. Dr. A. F. Jonas drained 
the gall-bladder of dark, thick, stringy 
bile. She made a good recovery 
from the effects of the operation, and 
in three weeks was up and around a 
little. She stopped the use of any 
drug and in a couple of months was 
doing her work and feeling well. 
About a year and a half later suffered 
from headache, vertigo, faintness, 
tinnitus, psychic irritability, dyspnea, 
palpitation, and edema, with tender¬ 
ness over the gall-bladder region; 
large quantities of bile and mucous 
were being vomited. She was using 
coal-tar products and morphine to 
relieve the pain. Her lips and finger¬ 
nails were blue. She had lost about 
20 pounds in weight during 4 to 6 
weeks. Overgaard (Western Med. 
Review, March, 1911). 

Recent years have fortunately shown 
very few cases of acute, or chronic 
poisoning, both the profession and 
the public having realized the dangers 
of acetanilide as an analgesic. 

Treatment of Chronic Acetanilide 
Poisoning—Under the gradual with¬ 
drawal of the drug, strychnine and 
digitalis, these cases usually recover 
promptly. If pains and insomnia 
occur, codeine may be used tentatively 
lest another evil habit be initiated. 
Constipation, which is apt to follow 
for a time, should be counteracted by 


ACETANILIDE (SAJOUS). 


219 


saline aperients. Sympathy and en¬ 
couragement are potent factors for 
good in these cases. 

The acetanilide—and this applies to 
all coal-tar analgesics—habit is much 
more easily recovered from than the 
opium and morphine habits, and 
oflfers, therefore, in this respect a 
marked advantage over the latter. 

Case of a^man, aged about 26, under 
treatment for two years for syph¬ 
ilis, who had taken enormous doses 
of the iodides. He had suffered 
greatly from headache and showed 
an obscure and progressive tendency 
to cyanosis. The character of the 
latter, with the cardiac symptoms and 
splenic enlargement, led to the diag¬ 
nosis of acetanilide poisoning. It was 
learned that the patient had had mi¬ 
graine previous to the specific infection 
and formed the liabit of taking various 
headache powders. Lately he had been 
using from six to twenty “orangeine” 
powders daily. Attempts to withdraw 
the drug being followed by intense 
headache, small doses of morphine were 
substituted without the patient’s knowl¬ 
edge. All the symptoms disappeared 
and the patient left the hospital with¬ 
out having taken either acetanilide or 
morphine for two or three weeks and 
without the knowledge that he had had 
the latter. The headache did not re¬ 
turn. J. C. Wilson (Boston Med. and 
Surg. Jour., Feb. 22, 1906). 

APPLIED THERAPEUTICS OF 
ACETANILIDE.—There is no ordi¬ 
nary acute febrile state (the tempera¬ 
ture remaining below 105.5° F.) in 
which the use of acetanilide as an 
antipyretic is warranted. In typhoid 
fever, for example, it causes, as shown 
above, and even when given in very 
small doses, marked depression tend¬ 
ing to collapse. It favors in no way 
the curative process, and the more or 
less sudden fall produced deprives the 
clinician of an important danger-sig¬ 
nal which points to intestinal hemor¬ 


rhage, and thus prevents the utiliza¬ 
tion of measures calculated to arrest 
it. The comfort acetanilide brings to 
the patient is the treacherous and 
insidious dulling of all sensations 
many poisons afford; it may be pro¬ 
cured quite as effectively and with 
benefit to the patient by means of 
cold baths, cool sponging, etc., by 
abstracting heat. Acetanilide does 
not shorten the course of fevers, 
does not prevent complications nor re¬ 
duce the mortality. The same reasons 
that prevail against its use in febrile 
processes cause acetanilide to be 
contraindicated in phthisis. It has 
been used to counteract the afternoon 
rise of temperature, but the advan¬ 
tage gained is more than offset by 
the depression produced. Ten grains 
in divided doses have caused collapse. 

Most authorities, however, advocate 
the use of acetanilide or other anti¬ 
pyretics of the coal-tar series when 
the temperature is sufficiently high to 
endanger life, i.e., in hyperpyrexia. 

It is in the diseases of the nervous 
system that acetanilide has shown 
itself most valuable. As an analgesic, 
especially in cases of neuralgia or 
neuritis, or in pain from reflex causes, 
acetanilide has been of marked bene¬ 
fit. In sciatica, migraine, intercostal 
neuralgia, gastralgia, the pain of optic 
neuritis and glaucoma, it has been 
freely used, and still maintains a well- 
deserved reputation. It is also effect¬ 
ive in the neuralgic pains associated 
with herpes zoster. 

All headaches that are severe or 
long-continued or of regular recur¬ 
rence should be carefully studied and 
the causative disorder treated. The 
most satisfactory temporary treat¬ 
ment in the author’s experience has 
been the following, varied according 
to age and other conditions:— 


220 


ACETANILIDE (SAJOUS). 


Acetanilidi ... (4.000). 

Sodii bromidi . 3ij (8.000). 

CaffeincE citrates . gr. iv (0.250). 

Elix. guarancs. .q. s. 5ij (60.000). 

One teaspoon ful every three hours for 
headache. E. M. Alger (Therap. Gaz., 
Dec., 1903). 

The painful menstruation, espe¬ 
cially in young girls, ovarian pain and 
the circulatory and nervous disturb¬ 
ances occurring at the menopause 
often yield to it. It has been used 
with benefit in chorea. 

[The manner in which acetanilide relieves 
pain in menstrual disorders, etc., is similar 
to that in neuralgia. 

In chorea, it is the hyperemia of the cere¬ 
brospinal and muscular systems which under¬ 
lies the choreic movements that is reduced 
by acetanilide. This drug sometimes proves 
a valuable adjuvant, moreover, to remedies 
addressed to the cause of the disorders. S.] 

In the lightning and girdle pains of 
tabes, acetanilide has been found very 
effective by Lepine, Grasset, Hayem 
and others. But 10-grain (0.66 Gm.) 
doses are required. These subdue the 
suffering in one-half hour and can be 
renewed when necessary. 

[This is produced in the same way, the 
pains being due mainly to hyperemia of the 
central and peripheral nervous elements, in¬ 
cluding the nervi nervorum. C. E. de M. S.] 

In epilepsy, acetanilide has, on the 
whole, not shown itself very useful, 
except in cases characterized by per¬ 
manently high vascular tension. At 
best, however, it serves but to defer 
the paroxysms. This applies also to 
tetanus. 

Vomiting of nervous origin or due 
to marked gastric irritability occa¬ 
sionally yields to its action. Two 
grains every hour until 6 grains have 
been taken usually suffice to arrest 
this morbid symptom. It gives some 
relief in seasickness in doses of 3 to 5 
grains (0.20 to 0.32 Gm.). 


In pertussis, acetanilide has been 
found to lessen the paroxysms mark¬ 
edly. It can be given in doses of % 
to grain (0.016 to 0.032 Gm.) in 
small children. 

Acetanilide has been used with ad¬ 
vantage in influenza. But, as antipy- 
rine and acetphenetidin are quite as 
effective and less prone to produce 
untoward effect, they should be given 
the preference. 

Increased comfort to the patient 
and occasionally general improve¬ 
ment have been secured by the use of 
acetanilide in diabetes mellitus. • 

In ordinary myalgias, especially 
lumbago, acetanilide proves some¬ 
times very effective. It relieves not 
only the pain, but also the stiffness. 
It has likewise been recommended in 
acute articular rheumatism, especially 
when the pain and swelling are 
marked. It should not be given when 
cardiac complications are present. 
Doses of 5 grains (0.3 Gm.) not 
oftener than three times daily usually 
suffice. 

Harnsberger found the drug useful 
in threatened abortion and in habitual 
miscarriages. 

The drug is sometimes used inter¬ 
nally in the treatment of coryza. 
In pharyngeal irritation and inflam¬ 
mation it is effective internally, 
especially when aided by a gargle 
of 4 grains (0.25 Gm.) to the ounce 
(30 c.c.) of water. Insufflations of 
acetanilide are very useful in tonsil¬ 
litis. 

[As these are all catarrhal processes in 
which hyperemia is the main morbid con¬ 
dition, the mode of action of acetanilide is 
self-evident. C E. de M. S.] 

LOCAL USES. —Acetanilide has 
been employed with benefit in cutane¬ 
ous disorders, such as eczema, psori- 





ACETIC ACID (SAJOUS). 


221 


asis, urticaria, and herpes, usually in 
an ointment. It may be used in 
powder form to dust over the initial 
lesion of syphilis, mucous patches, 
and chronic ulcerations, as well as 
chancroids. It has been employed in 
injections for the treatment of ure¬ 
thritis and vaginitis. The proportion 
of the drug used in ointment or liquid 
applications is generally from 20 to 
40 grains to the ounce. It has been 
extensively used as an antiseptic and 
analgesic in wounds and burns of 
varying extent, one of its main advan¬ 
tages being lack of odor. It is best 
used in combination with an equal 
part of finely divided boric acid. 

The danger of absorption and 
poisoning by the drug render its local 
use unwise, however, in any but 
minor injuries, and the quantity ap¬ 
plied at each dressing should not 
exceed that of a moderate dose given 
internally. Poisonous effects from 
absorption have been observed with 
especial frequency in infants. 

C. E. DE M. Sajous 

AND 

L. T. DE M. Sajous, 

Philadelphia. 

ACETIC ACID. —Acetic acid 
is an organic acid obtained from sugar 
or wood by distillation, or from ethyl 
alcohol by oxidation; or again from 
crude pyroligneous acid. It is also 
formed normally in the stomach, from 
sugars and alcohol taken as foods. 

PROPERTIES. —Acetic acid is a 
clear, colorless fluid having a strong 
pungent odor and an intensely acid cor¬ 
rosive taste. It contains 36 per cent, 
of glacial acetic acid: a monohydrate 
presenting the physical properties of 
acetic acid, which, in turn, becomes 
crystalline at 34° F. 


The dilute acetic acid is officially pre¬ 
pared by adding 1 part of acetic acid to 
5 of water. Good vinegar corresponds 
approximately in strength with dilute 
acetic acid. Each is used as a local 
astringent, and internally or by inhala¬ 
tion as a stimulant. 

Glacial acetic acid is employed as an 
escharotic. The crystalline form is 
mainly employed with sulphate of 
potassium in the preparation of smell¬ 
ing-salts. 

Trichloracetic acid prepared by treat¬ 
ing acetic acid with chlorine, which 
occurs in the form of deliquescent 
crystals, is to be preferred as an 
escharotic. 

USES AND DOSE.— The prepara¬ 
tions available are:— 

Glacial Acetic Acid (Acidum Accti- 
cum Glaciate) ; escharotic. 

Acetic Acid {Acidum Aceticum ); 
used externally. 

Dilute Acetic Acid {Acidum Aceti¬ 
cum Dilutum, 6 per cent.) ; dose, Yi to 
1 dram (2 to 4 c.c.). 

Trichloracetic Acid (Acidum Tri- 
chloraccticum) ; escharotic. 

It is miscible with alcohol or water 
in all proportions. 

PHYSIOLOGICAL ACTION.— 

Applied to the skin glacial acetic acid 
caused irritation and pain, and the for¬ 
mation of a vesicle; its local applica¬ 
tion to mucous membranes is attended 
by immediate blanching of the cellular 
elements cauterized. When applied to 
the skin well diluted, as vinegar, for 
example, it acts as an astringent and 
produces cold and pallor of the tissues 
it touches. Greatly diluted, as a bever¬ 
age, it quenches thirst. In the blood it 
combines with the alkaline bases, is 
transformed into acetates, and then into 
sodium bicarbonate, and thus acts as a 
diuretic and diaphoretic. 


222 


ACETIC ACID (SAJOUS). 


ACETIC ACID POISONING.— 

The abuse of vinegar, or vegetables and 
other foods preserved in this agent, 
tends to produce anorexia, gastric dis¬ 
orders, diarrhea and emaciation. In 
toxic doses acetic acid causes intense 
irritation, owing to its property of ef¬ 
fecting a partial solution of albuminous 
bodies and of dissolving gelatinous tis¬ 
sues. This escharotic action, by mani¬ 
festing itself upon the mucous mem¬ 
brane of the pharynx and larynx, is 
liable to cause edema of the glottis: a 
danger to be at once thought of. The 
immediate manifestations are severe 
pain in the mouth, throat, esophagus, 
and stomach, with retching and vomit¬ 
ing and other symptoms attending 
violent irritation of the digestive tract. 
General symptoms then manifest them¬ 
selves : The heart’s action becomes 
rapid and the pulse extremely weak or 
imperceptible, the face and extremities 
being cold and clammy and covered 
with sweat. In very acute cases, 
somnolence passes into coma, and death 
ensues. 

In moderately severe cases, there 
occurs, after the disappearance of the 
acute symptoms, abundant expectora¬ 
tion of mucous, containing necrosed tis¬ 
sue, and slight fever, due to more or 
less pyemia. The blood is markedly 
influenced, as shown by the marked 
anemia, paleness and distortion of the 
red corpuscles and other phenomena. 
Such a case usually recovers. 

Treatment of Acetic Acid Poison¬ 
ing.—Alkalies and demulcents should 
be employed. The bicarbonate of soda 
in free solution is an effective remedy. 
Ordinary soap—one containing an al¬ 
kali—can be used in solution until 
an alkaline salt is available. Chalk, 
lime or even wood ashes may be em¬ 
ployed in the absence of an alkaline 


soap. Milk, white of egg, oil or flax¬ 
seed tea are useful to form a coating 
over the esophagus and stomach. 

Case of a girl, aged 19 years, who 
swallowed a considerable amount of 
strong acetic acid with suicidal intent. 
She immediately was seized with violent 
vomiting and with pain and intense 
burning in the mouth and pharynx. At 
the hospital she developed a series of 
pronounced symptoms, which are inter¬ 
esting in view of the rarity of cases of 
acetic acid poisoning. There was a fre¬ 
quent and feeble pulse and a slightly 
elevated temperature, a persistent and 
violent cough with a very abundant 
purulent expectoration, a veritable bron- 
chorrhea, and occasionally efforts at 
vomiting which were not successful. 
The urine was black and smoky, like 
that of carbolic acid poisoning, and 
contained 1 per cent, of albumin. The 
red blood-disks in the fresh blood 
were very pale, with little tendency to 
form rouleaux, and with frequent mul¬ 
berry-shaped distortion. The serum, 
when separated, had a distinct reddish 
tint, showing that the hemoglobin 
had been dissolved from the cells. 
The heart-sounds and the apex-beat 
were very weak. The symptoms 
gradually disappeared, and the pa¬ 
tient was discharged cured. The 
treatment consisted of stimulation in 
the shape of injections of caffeine, a 
milk diet, and the use of pieces of ice 
and of a tannin gargle for the throat. 
Special attention called to the changes 
in the blood, the purulent bronchitis, 
and the degenerative changes in the 
myocardium resulting in heart-weak¬ 
ness with danger of cardiac failure. 
Giordano (Riforma Medica, Jan. 27, 
1904). 

Excellent results were obtained by 
the writer from lavage of the stom¬ 
ach preceded by a morphine injection 
to relieve the shock. The esophagus 
must be soothed by giving the pa¬ 
tient by mouth pure olive oil, 200 
Gm. (6^ ounces) in 24 hours, keep¬ 
ing this up for 7 or 8 days if needed, 
followed later by sweet cream, raw 
eggs, mucilaginous substances and 


ACETIC ACID (SAJOUS). 


223 


butter, and gradually ordinary solid 
food. Water can be given in the 
form of rectal injections of normal 
salt solution, 100 or 150 Gm. (3^ or 
5 ounces) every 2 hours, or by the 
drop method. The mouth should be 
kept clean and rinsed with some anti¬ 
septic solution. Of 120 cases of 
poisoning from various caustic sub¬ 
stances thus treated but 1 died. Dil¬ 
lon (Russky Vratch, xiv, No. 29, 
1915). 

To counteract the general symptoms, 
strychnine or caffeine may be used. 
To relieve the burning sensation in 
the alimentary canal, morphine is 
sometimes used. 

THERAPEUTICS.—As an anti¬ 
septic, acetic acid is possessed of con¬ 
siderable power. As such it may either 
be applied locally or its fumes may be 
inhaled. 

Acetic acid is frequently used as a 
stimulant. When inhaled its stimulat¬ 
ing effects upon the nervous supply of 
the nasal mucous membrane causes it 
to sometimes act rapidly in restoring 
consciousness after fainting. In the 
same manner it may also arrest vomit¬ 
ing and headaches of nervous origin. 

Acetic acid is useful in many dis¬ 
orders of the skin. As an escharotic it 
is often used on corns, warts, condylo- 
mata, and fungous growths. The gla¬ 
cial acetic acid should be used for this 
purpose. For the destruction of papil¬ 
lomata and other small growths, the 
trichloracetic acid is more effective. 
The neoplasm is first anesthetized with 
cocaine, and a single crystal of the acid 
is placed upon it. This produces a 
white, dry mass which falls off. In 
alopecia it has been used with advan¬ 
tage as a vesicant. When it is extensive 
the scalp should be shaved and dilute 
acetic acid with equal parts of chloro¬ 
form and ether applied. Or Besnier’s 
formula may be employed:— 


B Chlorali hydrati . 75 grs. 

Athens . 6 drs. 

Acidi acetici cryst . 15-75 grs. 


Misce. These applications are repeated 
two or three times a week at first, and later 
at longer intervals. 

Between times a stimulating oil—as 
of eucalyptus and turpentine, of each 
Yz. ounce; crude petroleum and alcohol, 
of each 1 ounce—is applied. This is 
to be followed by a thorough massage 
of the scalp for five minutes by the 
patient. Once a week, or oftener, the 
scalp is to be thoroughly shampooed 
with tincture of green soap (Morrow). 

In rodent ulcer and lupus vulgaris 
acetic acid is of use. Daily applications 
of a 75 per cent, solution and subse¬ 
quent rinsing with water are necessary. 

In sunburn and the various forms of 
dermatitis dilute acetic acid or vinegar 
limits greatly the cutaneous hyperemia, 
the main source of discomfort. 

Acute coryza is sometimes arrested 
by the inhalation of acetic acid. This 
applies also to epistaxis; in persistent 
cases, a tablespoonful of vinegar in a 
glassful of water hastens materially the 
beneficial effect inhalations afford. 

Glacial acetic acid is useful in pre¬ 
venting the development of hay fever 
by applications after local anesthesia 
with a 10 per cent, solution of cocaine 
to sensitive areas of the nasal mucous 
membrane twice per week. In prac¬ 
tically all cases, however, the applica¬ 
tions must be renewed each year. In 
hypertrophic rhinitis it may also be 
used in the same way; but chromic 
acid is more effective. In pharyngitis 
and tonsillitis gargling with equal parts 
of vinegar or dilute acetic acid and 
water sometimes proves very efficient. 

In tuberculous laryngitis it has 
given good results in arresting ulcer-' 
ation. The ulcers are first scraped 
and the acid applied with a laryngeal 





224 


ACETONEMIA. 


applicator. Inhalations of a 2- to 3- 
per cent, solution three times a day, 
ten minutes at a time, and contin¬ 
ued several weeks, have been recom¬ 
mended by several German observers. 

Acetic acid has also been found an 
excellent adjuvant in the treatment of 
pulmonary tuberculosis and bronchitis 
when used every three hours. A con¬ 
venient method is to pour about a 
teaspoonful on a saucer and to place 
this over a fire. The acid is then 
inhaled while it is evaporating—about 
ten minutes. At first it proves irri¬ 
tating, but this soon subsides. It is 
useful in night-sweats applied as a 
lotion. Vinegar half diluted with 
water is quite as effective. 

Diluted with from one to four parts 
of water, dilute acetic acid was recom¬ 
mended by Wood in hematemesis. It 
has been recommended by Hayem for 
dyspepsia, especially where the digest¬ 
ive activity is deficient, i.e., in hypo- 
pepsia. 

It is a good succedaneum for hydro¬ 
chloric acid in the treatment of gastric 
and acute or chronic intestinal ca¬ 
tarrh, ordinary vinegar, a tablespoonful 
to half a pint of water, being taken 
daily. It is indicated in those submitted 
to a diet rich in carbohydrates and un¬ 
able to take much exercise. It also 
controls summer diarrhea and true 
cholera nostras, vinegar rapidly and 
certainly killing the bacillus of cholera. 
Acetic acid has been found to dissolve 
fish-bones accidentally swallowed. 

Inhalations of acetic acid are very 
effective in the vomiting of chloroform 
narcosis, administered as in the “drop” 
method of anesthesia, the napkin be¬ 
ing held near the nose, but not in con¬ 
tact with the tissues. 

Dilute acetic acid or vinegar is effi¬ 
cient as a topical application for sprains 


and bruises and reduces greatly the ef¬ 
fusion and pain. 

C. E. DE M. Sajous 

AND 

L. T. DE M. Sajous, 

Philadelphia. 

ACETONEMIA .—There is consid¬ 
erable confusion at the present time be¬ 
tween acetonemia (due to the presence of 
acetone bodies, betaoxybutyric acid, ace- 
to-acetic acid and acetone in the blood) 
and “acidosis,” clinicians in general refer¬ 
ring to these conditions as if they were 
identical. So competent an observer as 
C. G. Kerley (77th Annual Session Amer. 
Med. Assoc., 1916) mentions cases in 
which there was a distinct acetonuria, and 
others in which there was a distinct 
acidosis. Those which showed acetonuria 
were children fed with too much milk. 
Most children of runabout age received 
too much fat and too much sugar. These 
show high fever; about 60 or 70 per cent, 
of them show acetonuria. A small percentage 
of cases of pneumonia, scarlet fever, and 
other conditions accompanied by a fever 
also show acetonuria. In these children 
the power of assimilation of carbohydrates 
seems to be held in abeyance and acidosis 
follows. Howland (ibid.) also urged that 
cases of recurrent vomiting were not due 
to acidosis, but to acetonuria, which is not 
acidosis. The latter occurs when there is 
a diminished alkali reserve, which causes 
recurrent vomiting only exceptionally. 
The only symptom of true acidosis is hy- 
perpnea, i.e., the exaggerated breathing of 
the air-hunger type; it may occur without 
fever or vomiting. Finally, Moore (Amer. 
Jour, of Dis. of Children- Sept., 1916) 
states that many cases of acidosis in in¬ 
fancy and childhood are not accompanied 
by an increase of acetone bodies in the 
blood sufficient to account for the severity 
of the acidosis. 

Diagnosis.—The presence of acetone in 
the blood of children —acetonemia—due to 
fat ingestion is associated, according to 
Silberstein (Miinch. med. Woch., July 23, 
1912), with markedly coated tongue, vom- 
ffirig» pallor, and fever. This syndrome 
sometimes follows the ingestion of cod- 
liver oil. Repeated attacks in the same 
child have been traced to the ingestion of 


ACETONEMIA. 


225 


whipped cream, milk, cheese, etc. A fruity 
odor of the breath and acetone in the 
urine usually accompany these attacks. 

Frdhlich (Norsk. Mag. f. Laegevidenska- 
ben, Apr., 1916) noted, besides the fore¬ 
going symptoms, thirst, oliguria, urticaria, 
herpes, pains in the joints, pruritus (the 
two latter also mentioned by J. P. Crozer 
Griffith), all of which may precede vomit¬ 
ing, mucomembranous colitis (Comby), 
and tachycardia. The vomiting may last 
from a few hours to several weeks. Im¬ 
provement sets in as suddenly as the at¬ 
tack began, acetone being eliminated in 
large amounts in the breath and urine im¬ 
mediately before, thus proving a connec¬ 
tion between the two. 

Blodgett (N. Y. Med. Jour., Aug. 28, 
1915), referring to cases of contagious 
disease, accompanied by acetone in the 
urine, states that in almost all there is a 
sore spot that can be found on deep pres¬ 
sure over the region of the pancreas. This 
spot can be distinguished from the abdom¬ 
inal muscular soreness that follows at¬ 
tacks of vomiting by the fact that it is 
only found on deep pressure, and is only 
2 inches in diameter, over the pancreas. 

It is difficult at times to distinguish 
between acute appendicitis and an at¬ 
tack of periodical vomiting with ace¬ 
tonemia. Palpation of the appendi¬ 
ceal region through the rectum is 
sometimes the only means to clear up 
the case. The writer advises in case 
of persisting doubt to remove the 
appendix. There is always a possibil¬ 
ity that the 2 affections may be asso¬ 
ciated. He reports 3 cases in which 
the profuse elimination of acetone by 
the breath and kidneys was accom¬ 
panied by frequent vomiting and 
occasional severe diffuse pains in the 
abdomen, the pulse fast and small, 
and the children were restless and 
felt badly, and there was no stool. 
The abdomen was distended but this 
was uniform, and no specially tender 
points could be found. While the 
surgeon was studying the first case 
with the internist, all the symptoms 
suddenly subsided. Gujdi (Rivista di 
Clin. Ped., Oct., 1917). 

The writer found a chemical 

method for estimating quantitatively 

1 


the acetone in the breath to deter¬ 
mine if acetone bodies are present 
in the body and in what amounts ot 
practical value in many cases, espe¬ 
cially in hyperpnea when acidosis is 
recognized or suspected. In diabetics 
it affords a rapid quantitative meas¬ 
urement of the amount present; it 
proves useful in diagnosing diabetic 
coma, and when coma is impending 
or changes in diet are being made. 
When the patient has been getting 
little or no food, as in fasting or re¬ 
current vomiting, the determinations 
of the acetone in the breath act as 
a guide to the patient’s condition. 
The test is briefly as follows: The 
air for the determination is collected 
in a rubber bag of 1000 c.c. capacity 
when full. Within 30 seconds after 
collecting the specimen, it is blown 
through the Scott-Wilson acetone re¬ 
agent. If acetone is present a white 
cloud is formed which reaches its 
maximum density in about 5 minutes. 
Higgins (Johns Hopkins Hosp. Bull., 
Dec., 1920). 

ETIOLOGY. —Referring to the peri¬ 
odical vomiting acetonemia of children; 
Frdhlich (ibid.) holds that defective utiliza¬ 
tion of fat as well as of carbohydrates 
plays some part in the disturbance. 
Hecker ascribed the greatest share in this 
periodical acetonemia to retarded develop¬ 
ment of certain organ-systems or groups 
of cells which are especially concerned in 
the digestion of fat, such children being 
at all times close to the limit of their 
digesting capacity for fat. Anything that 
causes them to step over this limit is 
liable to bring on a reaction, an intoxica¬ 
tion, manifested clinically by vomiting, 
prostration and elimination of acetone. 

TREATMENT. —Bucknell (Atlanta 
Jour.-Rec. of Med., Mar., 1916) deems it 
an error to state that while the cyclic at¬ 
tack is in progress little can be done to 
stay it. Many children vomiting for days, 
till nearly pulseless, may be promptly re¬ 
lieved. Body fluids being rapidly drained 
while there is inability to take liquids by 
mouth, water should be supplied by rec¬ 
tum, or, if diarrhea exists, by hypodermo- 
clysis. If the stomach contains irritating 

•15 


226 


ACETONURIA (LEVISON AND ERLANDSEN). 


substances, it should be washed out with 
sodium carbonate solution. The colon 
should also be irrigated, and a solution of 
sodium bicarbonate given per rectum, to 
be retained if possible. To depress the 
vomiting reflex, bromides and chloral hy¬ 
drate may be used by rectum, though 
chloretone gave the writer better results. 
Where vomiting is not too severe, a solu¬ 
tion of chloretone grains—0.1 Gm.—a 

few drops at a time, in a child about one 
year old) may be given by mouth, or 
through a stomach-tube, after stomach 
washing with sodium bicarbonate solution. 
To make up for the deficiency of carbo¬ 
hydrates 4 to 8 ounces (120 to 240 c.c.) of 
a 5 per cent, solution of dextrose should 
be administered, by rectum, in alternation 
with sodium bicarbonate solution already 
mentioned. After a few hours of treat¬ 
ment, vomiting usually ceases. If it re¬ 
curs, the enemas are to be repeated. As 
soon as the vomiting has ceased and a 
cathartic, such as calomel and milk of 
magnesia, has, if necessary, been given, 
feeding may be resumed. 

Fenner (N. O. Med. and Surg. Jour., 
Nov., 1914) considers it worth while to 
try the effect of fractional doses of calo¬ 
mel in the beginning. Soda is usually 
vomited, particularly if given in the large 
doses indorsed by so many authorities. 
At best, except in very weak solution, it is 
a nauseous dose. If frequently repeated 
it becomes a positive irritant. He has 
seen children of 2 to 2^2 years of age, who 
could retain their food, such as condensed 
milk, but who would begin to retch the 
moment the nurse approached with the 
dose of soda. Yet the soda was continued. 

The sovereign remedy for these cases, 
in his opinion, of vomiting is morphine. 
It may be given hypodermically, or in the 
milder cases by mouth, in very small 
doses, combined with a tiny dose of 
cocaine, and a few grains of magnesia in 
a little chloroform water or plain water. 
Once the vomiting has been arrested, one 
may attempt to neutralize the acid condi¬ 
tion with alkalies. The agonizing thirst 
and the dehydration of the tissues are met 
by the Murphy drip. During the slumber 
or drowsiness produced by the morphine, 
the rectal tube can be slipped in without 
arousing any protest from the baby. S. 


ACETONURIA. — Acetone 
(C 3 HoO= dimethylketone = CH 3 — 
CO—CH 3 ) is a thin, watery, very 
mobile, colorless liquid of neutral re¬ 
action. It has a curious aromatic 
odor, resembling somewhat that of 
acetic ether or of oil of peppermint. 
It is soluble in water, in alcohol and 
ether in all proportions; evaporates at 
ordinary temperatures; boils at 56.3° 
C., and has a specific gravity of 0.81. 
Acetone can be obtained by the dis¬ 
tillation of acetate of barium. Oxida¬ 
tion of acetone causes the formation 
of acetic acid and formic acid. As a 
product of metabolism, it was dis¬ 
covered by Fetters, in • 1857, in the 
urine of a diabetic patient. 

Acetone is found in the urine of 
healthy individuals in quantities not 
exceeding 10 mg. per day, which, dur¬ 
ing starvation (Muller), can increase 
to 780 mg. per day. In some diseases 
it increases to 0.2 to 0.5 gram daily.' 
By distilling the urine examined, ace¬ 
tone can be obtained in a purer state, 
although still united with other volatile 
constituents of the urine. 

PHYSIOLOGICAL AND PATH¬ 
OLOGICAL EXCRETION OF 
ACETONE. — Pathological acetonu- 
ria is observed ( 1 ) in high febrile 
states; ( 2 ) in diabetes, especially in 
advanced cases; (3) in some forms of 
carcinoma which have not as yet in¬ 
duced inanition; (4) in psychoses; 
(5) in autointoxication; ( 6 ) in func¬ 
tional insufficiency of the pancreas; 
(7) during the excessive use of animal 
foods, and ( 8 ) in different disorders 
of the digestion. Lorenz observed 
acetonuria and excretion of acetone 
with the feces and the vomited matter 
in a case of peritonitis. In fever ace¬ 
tonuria is constantly observed, and in 
the fevers- of children as well (Ba- 


ACETONURIA (LEVISON AND ERLANDSEN). 


227 


ginsky). In cases of diabetes,acetonu- 
ria occurs when the disease has con¬ 
tinued for a long time, and especially 
when the patients are put on an ex¬ 
clusive diet of proteids or proteids and 
fat, or when the allowance of food is 
hot sufficient to maintain the equilib¬ 
rium of metabolism. 

In fevers, as well as in diabetes, 
icetonuria is often accompanied by 
excretion of diacetic acid and beta- 
oxybutyric acid. 

Five cases of gastric disturbances ac¬ 
companied by elimination of acetone 
and acetic acid; the breath had the 
peculiar odor of acetone at times. Only 
a few of the children had fever during 
these attacks. The children were be¬ 
tween 3 and 11 years old. The writer 
ascribes the vomiting to efforts at 
elimination. Hecker (Munch, med. 
Woch., July 14, 1908). 

Case of periodical vomiting and ace- 
tonuria in a child. The patient was 
a boy of about 3, much depressed by 
the periodical vomiting. The odor of 
acetone permeated the air of the room. 
He had seven attacks of the recurring 
vomiting, each accompanied by much 
acetonuria, during the two years after¬ 
ward, but then he seemed to outgrow 
the tendency and is now an apparently 
healthy child. Adenoid vegetations 
had been removed in the interim. 
Bloch (Hospitalstidende, June 8, 1910). 

A temporary appearance-of consid¬ 
erable amounts of acetone bodies in 
the urine may be due to abnormal 
and irregular fermentation of sugars 
and starches in the intestine. They 
are absorbed therefrom to be ex¬ 
creted in the urine. These bodies are 
probably not very toxic per se, the 
serious general disturbance of cellu¬ 
lar metabolism in diabetes with aci¬ 
dosis being the cause of the gravity 
of the symptoms rather than the 
presence in the circulation of the ace¬ 
tone. Derham (Lancet, July 31, 
1915). 

Not only are acetonuria and aci¬ 
dosis not synonymous, but in the over¬ 


whelming majority of cases of ace¬ 
tonuria, acidosis is absent (see Aci¬ 
dosis, farther on in this volume). 
Acetone bodies may appear in the 
urine in considerable quantity with¬ 
out producing any disturbance. Aci¬ 
dosis, therefore, has come to mean 
the disturbance which results from a 
relative excess of acid radicals of any 
kind in the body, rather than the de¬ 
tection of one or more acids in the 
urine. If a moderate amount of di¬ 
acetic acid is formed it is neutralized 
and excreted in the urine. It is only 
with an excess of acid that the alkali 
reserve is diminished. Even then, 
though there is acidosis, there is no 
acetonuria unless the acids in excess 
are those of the acetone series. 
There is no justification for believing 
that acidosis due to the acetone 
bodies occurs in epidemic form. De¬ 
ficient food or increased requirement 
for food (disproportion between 
caloric intake and output) is the chief 
cause of acetonuria, but this rarely 
results in acidosis. The production 
of acetone bodies occurs at times 
when starvation cannot be held re¬ 
sponsible, and is sufficient to cause a 
severe or fatal acidosis, not neces¬ 
sarily accompanied by vomiting. This 
condition probably depends on the 
same underlying metabolic disturb¬ 
ance as do the majority of cases of 
recurrent vomiting. Howland and 
Marriott (Amer. Jour. Dis. of Child., 
Nov., 1916). 

It occurs also in association with 
typhus, pneumonia, variola, scarlet 
fever, perityphlitis, Bright’s disease 
and strangulated hernia, but it does 
not lead in such cases to diabetic 
coma. 

Costa found during the last month 
of physiological ptegnancy and in the 
puerperium (after the eighth day) a 
more marked acetonuria than in the 
non-pregnant state. In labor the 
acetonuria increases. Acetonuria can¬ 
not be regarded as a sign of fetal 
death. ' 


228 


ACETONURIA (LEVISON AND ERLANDSEN). 


ORIGIN AND PATHOLOGICAL 
SIGNIFICANCE OF ACETONE, 
DIACETIC ACID, AND BETA- 
OXYBUTYRIC ACID.— The origin 
of acetone in the organism has not 
yet been ascertained. Cantani was of 
the opinion that it was formed in func¬ 
tional disorders of the digestive tract ; 
Fetters and Kaulich argued that it 
was due to fermentations in the 
bowels. Markownikoff ascribed it to 
a fermentative product of sugar. 

Albertoni did not find acetone in the 
urine of animals which had received 
large doses of glucose (100 grams) or 
of different primary saturated alcohol; 
when isopropylalcohol was ingested it 
was excreted partly unaltered and 
partly changed to acetone, and when 
acetone was given to animals it was dis¬ 
charged by the urine, even if the dose 
of acetone ingested did not exceed 8 eg. 

When Gerhard detected the presence 
in the urine of a substance which gave 
a dark wine-red color by means of a 
solution of perchloride of iron, he be¬ 
lieved this substance to be diacetic ether, 
and was of the opinion that acetone was 
derived from this substance, which can 
easily be disintegrated into acetone, 
alcohol, and carbonic acid. 

Fleischer and Tollens then demon¬ 
strated that Gerhard’s view was erro¬ 
neous, and found that the coloring 
substance—at least in the majority of 
cases—must be diacetic acid, which 
can be separated from the urine by 
the addition of sulphuric acid and 
extracted with ether. This opinion is 
supported by von Jaksch. Minkowski 
caused acetonuria by extirpation of 
the pancreas, and von Mering by in¬ 
toxication with phloridzin. 

Lustig found that extirpation of the 
solar plexus in animals provoked ace¬ 
tonuria, glycosuria, and emaciation. 


while Oddi obtained the same results 
by sugar injections. 

Lorenz is of the opinion that diacetic 
acid and the beta-oxybutyric acid are 
the substances from which acetone is 
derived, and that they are the real 
causes of the toxic symptoms observed 
in acetonuria, while acetone itself is 
relatively innocuous. 

According to Geelmuyden, the neces¬ 
sary condition for the production of 
acetonuria is an insufficient decomposi¬ 
tion of carbohydrates; he thinks it 
probable that the bodies of the acetone 
series are formed in considerable quan¬ 
tity in the organism, to disappear later. 

Hubbard found acetonuria more fre¬ 
quent than is generally believed. Its 
presence without symptoms should 
not influence operative treatment or 
prognosis. While its presence with 
moderate symptoms is of but slight 
importance, its presence with severe 
symptoms renders the prognosis very 
grave. 

Von Engel found a great quantity of 
acetone in the urine of a patient suffer¬ 
ing from lactosuria; when the milk was 
removed by a sucking apparatus the 
acetonuria disappeared. Very much 
acetone was found in the urine of 
patients suffering from severe chronic 
morphinism. In different acute fevers 
acetonuria is rather a constant symp¬ 
tom ; in typhoid fever von Engel found 
it constantly; acetone was only missed 
when the typhoid fever was accom¬ 
panied by obstipation. 

Becker found that acetonuria in¬ 
creased after narcosis, the case being 
the same with an already existing 
acetonuria. This would seem to 
explain why acetonuria has been ob¬ 
served after great operations. 

Etherization itself will produce ace¬ 
tonuria in a certain number of cases, 


ACETONURIA (LEVISON AND ERLANDSEN). 


229 


but it also seems very probable that 
there are a good many other contrib¬ 
uting factors which must be taken into 
consideration, such, for example, as 
prolonged starvation before and after 
operation. In a large series of obser¬ 
vations made in a children’s hospital it 
was found that boys were more subject 
to postanesthetic acetonuria than girls. 
The length of the anesthesia, the 
amount administered-, and the duration 
of the operation seem to play no part 
in the duration and severity of the 
symptoms, but the method of adminis¬ 
tration of the ether seems to be of con¬ 
siderable importance, as a comparison 
of figures will show. In 120 cases 
etherized by the “cone method,” ace¬ 
tone was found in 88.5 per cent., while, 
in the same number of cases in which _ 
the drop method was used, only 26 per 
cent, showed acetonuria. It seems logi¬ 
cal, therefore, to consider the “drop 
method” the best. Hamblen (Univ. of 
Penna. Med. Bull., June, 1909). 

Eeesly, Longo, Young and Will¬ 
iams found postoperative acetonuria 
a quite common occurrence (70 per 
cent.). The condition is transient, 
lasting only from two to eight days 
(Young and Williams). Acetonuria 
has no influence upon the course of 
the recovery. Beesly holds that ace¬ 
tonuria due to chloroform anesthesia 
is more harmful than that caused by 
ether anesthesia, because ether is less 
injurious to the hepatic and renal cells 
and thus does not inhibit their power 
to carry on their eliminative functions. 

The usual risks of anesthesia are 
not increased by pre-existent chronic 
acetonuria, but anesthesia (especially 
by chloroform) may be dangerous 
with pre-existent acute acetonuria. 

The writers have made some observa¬ 
tions in 52 cases, of whom only 2, or 
about 3.8 per cent., had acetonuria be¬ 
fore operation, while following laparot¬ 
omy acetone was found in the urine of 
27, or about 52 per cent. The reaction 
lasted in different cases from two to 


eight days. Of the 2 patients whose 
urine contained acetone before opera¬ 
tion, 1 was a colored girl, 15 years of 
age, who was operated upon for adhe¬ 
sions following an acute attack of 
pelvic inflammation. The operation 
was short and the convalescence excel¬ 
lent. Young and Williams (Boston 
Med. and Surg. Jour., Jan. 23, 1908). 

Acetone occasionally accompanied 
by diacetic acid was eliminated in the 
urine of 182 out of 214 consecutive 
surgical patients observed by the 
writer. They were eliminated oftener 
and in larger quantities in women 
than in men. The severity of the op¬ 
eration and the amount of obvious 
shock had but little bearing on the 
amount of eliminated acid and the 
time of elimination. The more emo¬ 
tional, frightened, or anxious individ¬ 
uals invariably were more shocked, 
and also showed more acetone. 
Bradner and Reimann (Amer. Jour. 
Med. Sci., Nov., 1915). 

Acetone, diacetic acid, and beta- 
oxybutyric acid are found in great 
quantities in the urine of diabetic 
coma, and different authors—Munser 
and Strassez, for instance—believe 
these substances to be the real cause 
of coma, perhaps by causing an excess 
of acidity in the organism. 

In comatose patients who do not 
suffer from diabetes—as, for instance, 
in saturnine encephalopathies, etc.— 
diacetic acid is often found in the 
urine. Von Jaksch has proposed to 
give the name of “coma diaceticum” 
to these cases of coma. Nevertheless, 
neither acetone nor diacetic acid and 
oxybutyric acid have very prominent 
poisonous properties. Kussmaul gave 
animals 6 grams of acetone per day 
without effect. Buhl, Tappeiner, and 
Frerichs came to similar results. 
Albertoni found the lethal dose of 
acetone for dogs to be about 6 to 8 
grams per kilogram of the dog’s 
weight. 


230 


ACETONURIA (LEVISON AND ERLANDSEN). 


Geelmuyden draws the conclusion 
from many experiments on rabbits 
that, even when small (10 to 20 mg.) 
subcutaneous injections of acetone are 
given, the acetone is excreted with the 
urine; in larger doses more acetone is 
excreted; but only a portion of the in¬ 
jected quantity reappears; another 
portion of it is excreted with the ex¬ 
pired air; but still a portion is left 
which does not reappear and must 
therefore have been disintegrated in 
the body of the animal. After the in¬ 
jections albuminuria takes place. An 
adult rabbit can bear an injection of 2 
grams of acetone, but is killed by the 
injection of 6 grams. In starving 
animals the experiments gave the 
same results; a portion of the injected 
acetone reappeared in the urine and 
the expired air, while still another 
portion was disintegrated in the body. 
Geelmuyden draws from these experi¬ 
ments the conclusion that the aceto- 
nuria observed in starving individuals 
is not caused by a diminution of the 
power to disintegrate acetone already 
formed in the body, but to an increase 
of the amount of acetone formed in 
the body. 

Modern authors generally admit 
that acetone is a product of the me¬ 
tabolism of proteids. Honigmann and 
von Noorden are of the opinion that 
acetone is only formed by diminution 
of the organized albumin of the body, 
and never by the metabolism of the 
proteids ingested with the food, be 
the quantity ever so large. Hdnig- 
mann supported this theory princi¬ 
pally by experiments made on him¬ 
self, which proved that when he lived 
exclusively on large quantities of pro¬ 
teids—that is, when nutrition was in¬ 
sufficient—acetone and diacetic acid 
were found. The acetonuria was not 


augmented when more albumin was 
ingested, but disappeared when he 
took plenty of carbohydrates in addi¬ 
tion to the proteids. Von Engel, on 
the contrary, is of the opinion that in 
all cases when great quantities of 
albumin are decomposed in the body 
the quantity of acetone excreted with 
the urine will increase considerably,— 
equally if the albumin is ingested with 
the food or taken from the stock of the 
body. 

Weintraub and Hirschfeld are de^ 
cided opponents of this theory. Wein¬ 
traub argues that—in a case of severe 
diabetes where complete equilibrium 
of the metabolism, and especially of 
the metabolism of nitrogen, was main¬ 
tained for a long time, so that no 
albumin contained in the tissues was 
consumed—acetone, diacetic acid, and 
beta-oxybutyric acid were constantly 
excreted with the urine; the diet was 
free from carbohydrates; when, also, 
the quantity of proteids was some¬ 
what reduced the sugar disappeared 
after twenty-four hours; the weight 
of the body was maintained, but 
acetone and diacetic acid were still 
excreted (Magnus-Levy). 

Carbonate of soda augmented the 
quantity of acetone excreted, without 
diminishing the quantity of oxybuty- 
ric acids. When, in periods of twenty- 
four hours, no food at all was taken, 
acetonuria was greatly increased. 
Ingestion of carbohydrates dimin¬ 
ished the acetonuria, even in persons 
suffering from diabetes; levulose, 
milk, and sugar have the same prop¬ 
erty; glycerin, also, as observed by 
Hirschfeld. The addition of fat to 
the food has no power to arrest the 
acetonuria. 

Hirschfeld found that when he put 
two individuals on light diet, consist- 


ACETONURIA (LEVISON AND ERLANDSEN). 


231 


ing only of proteids and fat, diminu¬ 
tion of albumin of the body, as well 
as acetonuria, was produced. When 
carbohydrates were added to the food 
the acetonuria diminished, and that to 
a much greater degree than the 
diminution of albumin. Ingestions of 
fat had absolutely no influence in 
diminishing acetonuria, although it 
diminished the loss of nitrogen. Ace¬ 
tonuria is more marked when the 
albuminous food is scarce than when 
it is given in great quantities. The 
ingestion of carbohydrates has an 
extraordinarily rapid effect on the 
production of acetonuria, the quantity 
of acetone being considerable within 
two hours. 

Experiments in persons who were 
almost starving have proved that a 
moderate quantity of carbohydrates 
was sufficient to bring about marked 
diminution of acetonuria in spite of 
the considerable loss of albumin and 
fat which still took place. 

Geelmuyden, from his experiments 
on rabbits and dogs already men¬ 
tioned, reached the conclusion that 
acetone is formed in the tissues, not 
in the kidneys; that the kidneys give 
passage to the acetone, even when 
their blood contains a very small 
quantity of it, and that pathological 
acetonuria is not caused by a defect 
of disintegration of acetone in the 
body, but by a disorder of the general 
metabolism leading to the formation 
of an anomalous large quantity of 
acetone. Geelmuyden has further 
conducted a series of experiments in 
healthy individuals (medical stu¬ 
dents) put on different scales of diet, 
which were strictly controlled. As 
all observers did, Geelmuyden found 
that when a person was put on exclu¬ 
sive flesh diet acetonuria appeared, 


and at the same time the body lost 
albumin as well as fat; when large 
quantities of proteids were ingested, 
acetonuria was less considerable than 
when less albumin was given. Com¬ 
plete starvation, an exclusive fat diet, 
and a diet of proteids, with the addi¬ 
tion of a great quantity of fat, cause 
a very considerable amount of acetone 
to be excreted. As exclusive diet of 
fat and complete starvation give rise 
to the excretion of the largest quan¬ 
tity of acetone, it seems that acetone 
is formed by disintegration of fat, and 
that in this respect there is no dif¬ 
ference between the fat of the food 
and that of the tissues. Carbohy¬ 
drates have a great power to check 
the excretions of acetone; when 
individuals were put on a diet without 
carbohydrates and secreted urine con¬ 
taining a great quantity of acetone, 
the acetonuria disappeared in a few 
hours when carbohydrates were given. 
From 150 to 200 grams of carbohy¬ 
drates per day are required to check 
an already existing alimentary ace¬ 
tonuria. 

In the opinion of Geelmuyden, ace¬ 
tonuria occurs when carbohydrates 
are not ingested in sufficient amount, 
and acetone is formed by the disin¬ 
tegration of fat, either of that of the 
tissues or of that contained in the 
food. Schwarz and Waldvogel saw 
also an increase of acetonuria follow¬ 
ing the fat introduction per os. 

PRELIMINARY TESTS FOR 
ACETONE. —With an alkaline solu¬ 
tion of sodium nitrocyanide (of a 
slightly red hue) acetone gives a 
ruby-red color, changing, after some 
time, to yellow, and, after acidify¬ 
ing with acetic acid and boiling, to 
greenish violet. 

The cyanide of soda test, after Le- 


232 


ACETONURIA (LEVISON AND ERLANDSEN). 


gal or le Nobel (see below), may be 
employed as preliminary test; but, 
to make the presence of acetone posi¬ 
tive, it is necessary to separate it from 
the urine by distillation. As the boil¬ 
ing point of acetone is low (56.3° C.), 
this may be done at a low tempera¬ 
ture, and the use of a water bath is 
recommended. 

Legal’s Test. —To 10 c.c. of urine 
a small crystal of nitrocyanide of soda 
or some drops of a freshly made solu¬ 
tion' of this reagent are added; the 
fluid is rendered strongly alkaline by 
a 30 per cent, solution of caustic 
soda or potash. When acetone is 
present a beautiful red color will ap¬ 
pear, which will change only after 
some time to yellow; the red color 
produced in the same manner by 
creatinin becomes yellow sooner. Le¬ 
gal adds that, when acetone is pres¬ 
ent and the urine, shortly after the 
addition of the solution of soda, is 
neutralized with acetic acid, the urine 
assumes a purple-red color, and, when 
diluted with water, a crimson hue. 
When the acetic acid is floated on 
the urine a crimson ring will appear 
at the point of contact, and, when 
much acetone is present, the color of 
the ring will be purplish red. 

Legal’s test is rendered simpler 
and more reliable by substituting am¬ 
monia for the sodium hydrate. This 
avoids the disturbing creatin reac¬ 
tion. The urine to be tested is 
treated with glacial acetic acid and 
then with a few drops of a freshly 
prepared solution of sodium nitro- 
prussid; a few cubic centimeters of 
ammonia are then cautiously poured 
on top of the mixture. In case of the 
presence of acetone, a bright-violet 
ring appears at the point of contact. 
The violet ring grows brighter and 
brighter without spreading wider, 
irrespective of the quantities used in 
the test-tube or conical glass. The 


reaction was most distinct in the 
writer’s tests when 15 c.c. of urine 
and from 0.5 to 1 c.c. of acetic acid 
were used. Acetone, 0.025 per cent., 
is readily detected by this test. Alco¬ 
hol and aldehyde do not give the re¬ 
action. Lange (Miinch. med. Woch., 
Bd. liii, Nu. 36, 1906). 

Neither Legal’s, Chautard’s, nor 
Lieben’s test will detect small quanti¬ 
ties of acetone when performed with 
urine without distillation. After dis¬ 
tilling, the iodoform test (Lieben’s) 

, is very satisfactory, provided the de¬ 
tection is made by examining micro¬ 
scopically for crystals in form of 
hexagonal plates or small stars rather 
than by the odor of iodoform. This 
test, although reliable, is tirne-con- 
suming. The writer therefore, pre¬ 
fers Frommer’s test, which may be 
applied to the urine direct. It is as 
follows: About 10 c.c. of urine are 
treated with about 1 Gm. of sodium 
hydroxide in substance, and, without 
waiting for it to dissolve, 10 or 12 
drops of a 10 per cent, solution of 
salicylaldehyde in absolute alcohol 
are added. The mixture is heated to 
70° C. In the presence of acetone a 
marked purple-red color develops at 
the zone of contact with the alkali. 
This test can indicate the presence of 
0.000001 Gm. acetone in 8 c.c. of 
water. 

Unless the urine is diluted so that 
its specific gravity is reduced to about 
1.010, confusing colors occur that ren¬ 
der interpretation difficult. When it 
is properly diluted, however, urine 
containing only minute or normal 
quantities of acetone will give, after 
10 or 15 minutes’ standing, a straw or 
faintly pink color. Checked against 
the iodoform test, the Frommer reac¬ 
tion was found very reliable. Muhl- 
berg (Med. Rec., Dec. 27, 1913). 

Le Nobel’s Test. —Le Nobel and 
Fehr hold that Legal’s test is only 
reliable when much acetone is pres¬ 
ent, and that, when there is only a 
small quantity of it in the urine, the 
test may be fallacious, since other 
substances contained in the urine can 


ACETONURIA (LEVISON AND ERLANDSEN). 


233 


produce a red color with the nitro- 
cyanide of soda. The most charac¬ 
teristic point of the test is, according 
to Fehr, the appearance of the violet 
hue, which causes the red color to 
become crimson or purple, and not 
pure red. 

Le Nobel proposes to substitute a 
solution of ammonia for the solution 
of soda, when the test is, in other 
respects, made according to the indi¬ 
cations of Legal; the fluid containing 
acetone is not immediately colored, 
but after some time, when the liquid 
is shaken with air or some drops 
of a strong acid added (the alka¬ 
line reaction being maintained), the 
fluid takes a rose-red color, increas¬ 
ing gradually and changing after 
some time to violet wine red. By 
heating the fluid the color disap¬ 
pears, but returns on cooling down; 
when boiled with acids it changes 
into greenish violet. Le Nobel’s test 
is more delicate than Legal’s, and 
will reveal 0.00025 gram of acetone. 

Lange thinks the contact reaction 
gives a more distinct picture than 
the mass reaction, and modified le 
Nobel’s test in that direction: 15 cm. 
of urine are mixed in a reagent glass 
with 0.5 to 1 c.c. of acetic acid and a 
few drops of solution of sodium nitro- 
prusside. On floating a small amount 
of ammonia upon this mixture an 
intense violet ring develops at the 
point of contact. 

Jackson Taylor also modified le 
Nobel’s test. He adds strong am¬ 
monia to a fresh-prepared solution 
of sodium nitroprusside and urine. 
The ammonia solution remains on 
the top. There appears—if acetone 
be present—a well-marked and abso¬ 
lutely characteristic ring of magenta 
(or petunia) within one to three 


minutes, and gradually spreads up¬ 
ward, pervading the whole of the 
ammonia solution if acetone is pres¬ 
ent in considerable amount. 

Fehr’s Test.—Fehr also employs 
the test after the method of Legal, 
but proposes, when the color of the 
urine after the addition of solution 
of soda is passing from dark red to 
yellow, to float some drops of acetic 
acid on the urine. When the test- 
tube is slightly rotated so that only 
a small quantity of the acid mingles 
with the urine, a beautiful violet color 
will appear when acetone is present, 
the intensity of the color being pro¬ 
portionate to the quantity of acetone 
contained in the urine. 

Chautard’s Test.—Romine recom¬ 
mends, as a reliable test for acetone 
in the urine, a solution of fuchsin 
(1:2000) into which a current of 
sulphurous acid gas has been passed. 
This rapidly decolorizes the liquid 
and causes it to assume a clear yel¬ 
low tint, which is permanent and 
unaffected by an excess of acid. A 
few drops of such a solution, added 
to a urine containing acetone, pro¬ 
duce a deep violet color. The test 
is delicate enough to allow the de¬ 
tection of 1 part of acetone in 1000 of 
urine. 

DEFINITE TESTS FOR ACE¬ 
TONE.—When no very great quan¬ 
tity of acetone is found in the urine 
it is absolutely necessary to distill 
the urine and to test the distillate 
with the different reagents. The dis¬ 
tillation of 200 to 300 c.c. of urine 
(always fresh, since acetone can dis¬ 
appear when the urine has to stand 
hours in a warm place) is made, in 
a water bath, and a temperature of 
56° to 58° C. employed. No acid 
need be added to the urine before 


234 


ACETONURIA (LEVISON AND ERLANDSEN). 


distillation, as the acetone becomes 
distilled very well without acid and 
the acid might disintegrate other sub¬ 
stances present and thus cause the 
formation of acetone. There is no 
reason why special care should be 
taken lest a small amount of ammo¬ 
nia be distilled with the acetone. 
The distillation is only continued 
until a sufficient quantity of fluid for 
the different tests to be employed 
has passed over into the recipient. 
The distillation is then subjected to 
the following tests:— 

Lieben’s Iodoform Test.—To a few' 
c.c. of the distillate a few drops of a 
solution of potassium and some drops 
of a solution of iodine and iodide 
of potassium are added, the solution 
of potassium being added in excess.. 
When acetone is present, a thick, 
yellow precipitate of iodoform will 
immediately form. This test will re¬ 
veal 0.01 mg. By heating, the iodo¬ 
form evaporates and accumulates on 
the sides of the test-tube in the form 
of small yellow plaques, consisting 
of the characteristic crystals (hex¬ 
agonal plaques and stars) of iodoform. 
The most serious objection to Lie¬ 
ben’s test is that many (at least sev¬ 
enteen) other substances, and espe¬ 
cially alcohol, may give the same 
result. 

Gunning’s Test.—Gunning modified 
Lieben’s test by using a solution of 
ammonia and tincture of iodine. Le 
Nobel prefers to use a solution of 
ammonia and iodine dissolved in io¬ 
dide of ammonium; this certainly is 
the best way to make the iodoform 
test, as no alcohol is added with 
the reagents. According to le Nobel, 
0.001 mg. of acetone can be detected 
by this test, but von Jaksch could 
only detect acetone by it when pres¬ 


ent in a quantity of 0.1 mg. Errors 
caused by the presence of alcohol 
and aldehyde are avoided by this test. 

Reynold’s Test.—Freshly precipi¬ 
tated oxide of mercury is dissolved 
by acetone in the presence of alkali. 
Le Nobel prefers to make the test 
by precipitating a solution of per- 
chloride of mercury with an alcoholic 
solution of caustic potash, added until 
the mixture gives a strong alkaline 
reaction; then the fluid containing 
acetone is added and the whole well 
shaken in a test-tube. The fluid is 
then filtered and care taken that the 
filtrate be perfectly limpid. The com¬ 
bination of acetone and oxide of mer¬ 
cury in the filtrate can be detected by 
chlorate of stannum or by floating 
some drops of the filtrate on a solution 
of sulphide of ammonium: where the 
two liquids touch each other a black 
ring will appear. By means of this 
test 0.01 mg. of acetone is revealed, 
but aldehyde is also able to dissolve a 
rather considerable quantity of mer¬ 
curic oxide. 

The Nitrocyanide Test.—This test 
is made with the distillate quite in the 
same manner as with the urine, either 
after the method of Legal or after le 
Nobel’s modification of it. This test 
is less delicate, and the phenols, which 
possibly might have passed over into 
the distillate, are apt to give the same 
color as the acetone; the test, there¬ 
fore, gives no proof of the presence of 
the latter substance. 

Penzoldt s Indigo Test.—Baeyer 
and Drewsen found that acetone 
forms indigo blue with orthonitroben- 
zaldehyde. Penzoldt has employed 
this reagent by dissolving crystals 
of orthonitrobenzaldehyde in boiling 
water; on cooling down the aldehyde 
forms a white, milky cloud; the fluid 


ACETONURIA (LEVISON AND ERLANDSEN). 


which is to be tested is now added and 
the mixture rendered alkaline with a 
solution of sodium hydrate. When 
acetone is present a yellow color will 
appear, which changes to green and, 
after ten minutes, to indigo; it also 
forms an indigo-blue precipitate. 
Very small quantities of acetone may 
be detected by shaking the mixture 
with a few drops of chloroform. When 
left quiet for some time the chloro¬ 
form takes a blue color and sinks to 
the bottom of the test-tube. 

According to Penzoldt, acetone is 
revealed by this test in a solution of 1 
to 2000. According to von Jaksch, the 
smallest quantity of acetone revealed 
by it is 1.6 mg. Aldehyde acetophe¬ 
none and other substances form in¬ 
digo in the same way as acetone, but 
the color is not so marked. 

Malerba’s Test.—Malerba found 
that a Yi per cent, solution of parami- 
domethylaniline with acetone gives a 
reddish color, changing into violet and 
blue-red. 

Riegler describes the following test: 
15 cm. of urine are acidulated with 
5 to 10 drops of concentrated sul¬ 
phuric acid. When 2 to 3 c.c. of an 
aqueous solution of iodic acid are 
added, an intense pink color will ap¬ 
pear, which is not taken up by chloro¬ 
form. The test has been found to be 
specific and active where Legal’s test 
fails. 

Frommer renders the urine strongly 
alkaline with potassium hydrate and 
adds several drops of a 10 per cent, 
solution of salicylic aldehyde, and 
heats to 70° C. A purple ring appears 
if the reaction is positive. 

Miscellaneous Tests.—With bisul¬ 
phite of soda, acetone, as well as the 
aldehydes, combines to a crystallic 
compound in thin flakes resembling 


235 

those of cholesterin, even by micro¬ 
scopic examination (Limpricht). 

Acetone in an alkaline solution com* 
bines with iodine to form iodoform. 

Freshly precipitated oxide of mer¬ 
cury is dissolved by acetone. Indigo 
is formed when acetone is combined 
with orthonitrobenzaldehyde in an 
alkaline solution. (Baeyer and Drew- 
sen.) 

From what has just been stated it 
will become apparent that not one of 
the tests is specific for acetone alone. 
To be quite sure that acetone is 
contained in the distillate, it is nec¬ 
essary to try successively by all the 
tests, and only when all tests give 
positive result is the presence of 
acetone proved. 

A. E. Taylor is of the opinion that 
only the tests described by Stock and 
Deniges are really good and reliable 
and should replace the tests with 
Lugol’s solution, mercuric oxide and 
sodium nitroprusside. 

The only two really good tests for 
acetone in the urine are that of Stock, 
described in 1899, and that of Deniges, 
described in 1898. These are certain in 
their results and easy of execution, and 
should replace the fallacious tests with 
Lugol’s solution, mercuric oxide and 
sodium nitroprusside. The two tests 
agree; the writer has never had the 
Stock test present without the Deniges 
test being also positive. The Stock test 
is less sensitive than the other, but this 
is considered an advantage for prac¬ 
tical purposes. The author has often 
found acetone present by these tests 
without obtaining the reaction for 
diacetic acid, for which he also gives 
the method; but he has never found 
diacetic acid present without acetone. 
A. E. Taylor (Jour. Amer. Med. Assoc., 
Mar. 17, 1909). 

he quantitative estimation of the 
acetone bodies is often most impor¬ 
tant as an indicator of the degree of 


236 


ACETONURIA (LEVISON AND ERLANDSEN). 


derangement of metabolism and aci¬ 
dosis that may be present. 

Von Jaksch has tried to employ the 
nitrocyanide test for a quantitative 
estimation of the acetone, and the 
iodoform test has been recommended 
by Messinger and Huppert for the 
same purpose. The quantity of iodine 
used to form iodoform with the ace¬ 
tone is measured (titrated), and the 
quantity of the acetone present in the 
solution calculated by it also; but, 
although Engel and Devoto are of the 
opinion that it is possible to make 
pretty accurate estimations in this 
way, methods for quantitative estima¬ 
tion of the actone are not to be relied 
upon, as it is impossible to avoid 
errors caused by the presence of sub¬ 
stances which are influenced by the 
tests in the same way as the acetone. 

Diacetic acid (C 4 H 603 =CH 3 —CO 
—CH 2 —COOH) may be revealed in 
the urine by the aid of a solution of 
perchloride of iron (Gerhardt’s test), 
which, with diacetic acid, produces 
a dark wine-red color. The test is 
made by adding a solution of per¬ 
chloride of iron as long as a precipi¬ 
tate of phosphates of iron is formed. 
The mixture is then filtered and some 
drops of perchloride are added to the 
filtrate. When diacetic acid is present, 
the filtrate takes a deep-red color, 
which vanishes in twenty-four hours, 
and more rapidly after addition of 
strong acids. Von Jaksch has, by a 
colorimetric method based on this test, 
tried to make an approximate estima¬ 
tion of the quantity of diacetic acid 
contained in the urine, but newly 
passed urine can alone be used for the 
search of diacetic acid, as this acid, 
after some time—twenty-four to forty- 
eight hours—will disappear from the 
urine. Diacetic acid can be isolated 


from the urine by adding a few drops 
of sulphuric acid and shaking the 
mixture with ether. When diacetic 
acid is present, it is dissolved in the 
ether and can be detected by the per¬ 
chloride of iron test. 

Beta-oxybutyric acid (C 4 H 8 O 3 ) is 
also found sometimes in the urine of 
fever patients, as well as in diabetes, 
with acetone and diacetic acid. This 
may also be the case in the dyspepsia 
of alcoholism and in carcinoma of the 
stomach, scarlatina, measles and scor¬ 
butus. When beta-oxybutyric acid is 
cautiously oxidated, acetone is found. 

For general practice the exact quan¬ 
titative determination of the acetone 
bodies is rather complicated. To 
overcome this difficulty, Stuart Hart 
(1908) devised a procedure based on 
the delicacy of the well-known test- 
tube reactions in urine. The urine is 
first tested for Gerhardt’s reaction. If 
positive, we know the acetone bodies 
to be present in excess of 0.2 Gm. per 
liter. If the reaction is very strong, 
the test solution is diluted with dis¬ 
tilled water until the color approxi¬ 
mates that of the standard ferric 
chloride solution, and this dilution, 
when compared in one of the author’s 
tables, gives the amount in Gm. per 
liter. 

If Gerhardt’s reaction proves nega¬ 
tive, Arnold s. Legal’s and Lieben’s 
tests are tried in the order named. A 
positive Arnold reaction indicates Ca 
0.1 Gm. per liter; positive Legal reac¬ 
tion Ca 0.03 Gm. per liter. If only 
Lieben’s test is positive, the amount 
of acetone is within the normal limits. 
(See Acidosis, this volume.) 

F. Levi SON 

AND 

A. Erlandsen, 
Copenhagen. 


ACETOZONE. 


ACETPHENETIDIN (SAJOUS). 


237 


ACETOZONE, a germicide and de¬ 
odorant (accepted by the A. M. A. Coun¬ 
cil) formerly known as benzosone, is a 
mixture of acetylbenzoyl peroxide and an 
inert absorbent powder. It was introduced 
by Freer and Novy, of the University of 
Michigan. Its properties resemble those 
of hydrogen peroxide, though, according 
to its discoverers, it is over one hundred 
times more active as a germicide. 

Acetozone, in its original form, occurs 
as white shining crystals, but is marketed 
in the form of a powder. The latter should 
be kept perfectly dry, but it should not be 
exposed to heat, which decomposes and 
volatilizes it. It is also rapidly decom¬ 
posed by organic substances and should 
not be administered after a meal. 

Modes of Administration.—Acetozone is 
usually employed in the following manner: 
“Add the powder to warm water in the 
proportion of 15 grains to the quart; shake 
vigorously for five minutes, and allow to 
stand for about two hours. Decant off the 
liquid as required. If the patient objects 
to the taste, a little extract of orange or 
lemon, or orange or lemon juice, ginger 
ale, carbonated water, or fruit syrup may 
be added to each dose as taken.” It may 
also be given in capsules, but followed at 
once by a copious draught of water. 

It is soluble in water to the extent of 
1 : 1000 to 10,000; in its crystalline form in 
oils to the extent of about 3 per cent, and 
slightly soluble in alcohol, ether, and 
chloroform, but all these solvents grad¬ 
ually decompose it. This does not apply 
to neutral petroleum oils, however, and 
an '‘acetozone inhalant” is available which 
contains 1 part of acetozone, Vz part of 
chloretone, and 98.5 parts of refined liquid 
petroleum. It may be given in an ointment, 
using solid or liquid petrolatum as excip¬ 
ient, beginning with Yz per cent, strength. 
An aqueous solution may be used as spray 
and as a deodorizer and antiseptic for stools, 
sputum, etc. 

Therapeutics.—Acetozone is used for its 
marked oxidizing and germicidal action 
mainly for the treatment of diseased 
mucous membranes. It has been credited 
with a favorable action in typhoid fever, 
the main effect being decrease of the fetor 
of the stools, subsidence of the tympanites 
and diarrhea, and prevention of hyper¬ 


pyrexia. Good results have been obtained 
in Asiatic cholera. In ophthalmology, a 
solution of 1 grain to 2 ounces of water, 
instilling 1 drop or 2 every hour, has been 
found useful in corneal infections. In 
laryngology, tonsillitis and atrophic rhi¬ 
nitis have seemed to be beneficially in¬ 
fluenced. This applies also to infected 
wounds, gonorrhea, and chancroid. It has 
been found an excellent deodorant in gan¬ 
grene and malignant small-pox. 

Acetozone is a very efficient bac¬ 
tericide and antiseptic for use in the 
treatment of war wounds. It may be 
used in strengths of from 5 to 10 
grains (0.3 to 0.6 Gm.) to the pint 
(500 c.c.) for wet dressings and irri¬ 
gations and to saturate gauze. It 
can also be used in the stronger solu¬ 
tions by Carrel’s method. In very 
septic cases the strengths may be 
raised to 20 or even 60 grains (1.3 to 
4.0 Gm.) to the pint (500 c.c.). The 
solution keeps fairly well, but should 
be made fresh every week. Bacterio¬ 
logical tests showed that it was 
markedly germicidal toward Staphy¬ 
lococcus pyogenes as well as the 
anaerobic Bacillus mycoides, which is 
a spore bearer. Its germicidal power 
is considerably reduced, however, in 
the presence of serum, broth, or pus, 
but it still remains fairly efficient. C. 
Gore-Gillon and R. T. Hewlett (Brit. 
Med. Jour., Aug. 18, 1917). S. 

ACETPARAMIDOSALOL. 

See Salophen. 

ACETPHENETIDIN.— 

(acetphenetidinum; para-acetpheneti- 
din), commonly known under the pro¬ 
prietary name of phenacetin, is a coal- 
tar product, obtained by treating para- 
phenetidin with glacial acetic acid. It 
is an acetyl derivative [C 6 H 4 . OC 2 H 5 . 
NH CH 3 CO]. of para-amidophenol. 

PROPERTIES. —Acetphenetidin oc¬ 
curs in the form of a white, odorless, 
and practically tasteless powder, com¬ 
posed of small, needle-like or scaly crys¬ 
tals. 


238 


ACETPHENETIDIN (SAJOUS). 


DOSE. —Five to 10 grains (0.32 to 
0.65 gram) in adults; 1 to 5 grains (0.065 
to 0.32 gram), according to age, in chil¬ 
dren. The maximum amount to be 
given in twenty-four hours, according to 
Pouchet, is 30 to 45 grains (2.0 to 3.0 
grams), which should be distributed 
during the day in several doses, each not 
exceeding 7% grains (0.5 gram). The 
tendency is toward a marked decrease 
of this amount. 

Out of 297 observers using acet- 
phenetidin, 10, or 33 per cent., em¬ 
ployed less than 2 grains as a minimum 
dose for adults; 90, or 30.3 per cent., 
employed 2.5 grains or less as a mini¬ 
mum dose; 188, or 63.3 per cent, em¬ 
ployed from 3 to 5 grains as a minimum ■ 
dose; 89, or 29.9 per cent., used doses 
exceeding 5 grains, while 208, or 70 
per cent, never exceeded a dose of 5 
grains. 

An examination of a number of 
prescriptions for adults on file in vari¬ 
ous pharmacies in Washington, D. C, 
showed that the average dose of acet- 
phenetidin prescribed was 1.92 grains. 
Kebler, Morgan, and Rupp (U. S. Dept, 
of Agricul., Bureau of Chemistry, Bull. 
No. 126, July 3, 1909). 

MODES OF ADMINISTRA¬ 
TION. —Acetphenetidin is almost in¬ 
soluble in cold water (1 grain in 2 
ounces), more freely soluble in boiling 
water (1 grain in 1 dram), and read¬ 
ily so in alcohol (1 grain in 12 minims) ; 
it will also dissolve in glycerin and lac¬ 
tic acid. 

Being almost tasteless, it is easily 
taken in powder form; it can also be 
given in capsules, cachets, or tablets. 
When combined with other remedies in 
liquid preparations it is best kept in 
solution by dilute alcohol.' Thus a mix¬ 
ture of acetphenetidin, sodium bromide, 
and caffeine in the elixir of licorice is 
frequently prescribed for the relief of 
headache. A good formula is the 
following:— 


R Acetphenetidini . gr. xv (1.0 Gm.). 

Caffeines citratce . gr. viij (0.5 Gm.). 

Sodii bromidi . 5j (4.0 (jm.). 

Elixiris glycyrrhizcB. (30.0 c.c.). 

M. Sig.: Two teaspoonfuls, repeated if 
necessary. Shake well. 

Where nausea and vomiting accom¬ 
pany headache, oral administration be¬ 
ing, therefore, unsuitable, acetpheneti¬ 
din may be administered by the rectum 
in 1 or 2 drams of water (Brunton). 

Acetphenetidin is sometimes used lo¬ 
cally in powder form or in an ointment 
or alcoholic preparation. 

INCOMPATIBILITIES.— Acet¬ 
phenetidin is incompatible with iodine, 
nitric acid, and oxidizing agents gener¬ 
ally; also with chloral hydrate, phenol, 
and salicylic acid. 

CONTRAINDICATIONS.—These 

are the same as those of acetanilide 
{q-v.), though the dangers from its use 
are less marked than with the latter 
drug. It is advisable not to employ it 
in cases of heart disease, pulmonary 
tuberculosis, grave anemia, or in per¬ 
sons markedly enfeebled from any 
other cause. 

PHYSIOLOGICAL ACTION.— 
As Antipyretic.— Acetphenetidin is the 
safest and most frequently employed 
of antipyretic remedies. In common 
with acetanilid, it has little or no influ¬ 
ence on the temperature of normal indi¬ 
viduals in therapeutic doses, but causes 
a fall in febrile cases. According to 
Crombie and Hirschfelder, the greatest 
1 eduction is not produced until three or 
four hours after administration. The 
average decline may be put down as 
3.6° F. (2° C; Manquat). The reduc¬ 
tion may last six to eight hours, and is 
free of unpleasant effects, excepting a 
mild sweat (Pesce). Cerna and Carter 
found that acetphenetidin produced a 
very slight fall of temperature during 
the first and second hours after inges- 





ACETPHENETIDIN (SAJOUS). 


239 


tion, and that the effect reaches its 
height in the third hour. They believe 
that the fall of temperature results 
chiefly from a decrease in heat produc¬ 
tion, together with a slight increase in 
the heat dissipation, less marked than 
in the case of antipyrin. Probably the 
delayed action of the drug depends on 
its insolubility. It should be mentioned, 
however, that certain authors describe 
its effect as being more prompt, and 
comparable with that of acetanilide. 

With regard to the manner in which 
the antipyretic effect is produced, the 
prevailing belief is that it depresses the 
heat-regulating centers. 

As Analgesic.—Acetphenetidin is 
considered to exert a sedative effect 
upon the nervous system. Its anodyne 
influence is more marked than that of 
acetanilide or antipyrin. It is believed 
to depress the nerve-centers, in common 
with the other antipyretics, but it has 
probably also some action on the sen¬ 
sory nerves, since it frequently relieves 
neuralgic pain without giving evidence 
of any central depressant action by the 
production of drowsiness or mental 
apathy. 

Injected into animals, large doses of 
acetphenetidin are required before its 
effects on the nervous system appear. 
Using doses of 0.5 to 1 Gm. per kilo of 
body weight in rabbits, Mahnert ob¬ 
served merely a muscular weakness, 
lasting a few hours, which he ascribed 
to a depressing action on the spinal 
cord. With doses of 3 Gm. per kilo he 
obtained a short period of spinal excita¬ 
tion, followed by one of complete motor 
and sensory paralysis, with loss of re¬ 
flexes and early death. In frogs the 
preliminary spinal excitation may be 
such as to produce convulsions. In 
mammals convulsions produced by^ the 
antipyretics may be of cerebral, spinal. 


or, possibly, asphyxial origin (Cushny). 
H. C. Wood, Jr., and H. B. Wood 
watched the effects of acetphenetidin 
on frogs when absorbed through the 
skin from a saturated solution. Like 
Mahnert, they noted a sluggishness of 
movement and loss of muscular power, 
proceeding steadily to complete paraly¬ 
sis, with final cessation of the heart 
beats. In addition, they found that the 
motor nerves and the muscles, though 
soaked in saturated acetphenetidin so¬ 
lution, continued responsive to electric 
stimulation throughout the period of ac¬ 
tion of the drug, and even after death, 
and concluded, therefore, that the loss 
of reflexes and paralysis observed had 
been of spinal origin. They ascertained 
that doses of 0.5 Gm. per kilo, injected 
into the jugular vein of a dog, caused 
death from paralysis of respiration. 

Local applications of acetphenetidin 
have some analgesic effect. 

On the Circulation.—Conflicting 
views have been advanced by different 
observers concerning the effects of the 
drug on the blood-pressure. Cerna and 
Carter found that, in moderate doses, it 
caused a rise of the arterial pressure by 
directly stimulating the heart’s action, 
and also, probably, the vasomotor sys¬ 
tem, while in large doses it decreased 
the pressure, chiefly by its influence on 
the heart. They also state that acet¬ 
phenetidin tends to increase the pulse 
rate, mainly by cardiac stimulation, and 
possibly, also, by influencing the cardio- 
accelerator apparatus, while later, es¬ 
pecially with large doses, it decreases 
it primarily by stimulating the cardio- 
inhibitory centers, and later b> depress¬ 
ing the heart. Ott and H. C. Wood, 
Jr., on the contrary, assert from their 
experiments that acetphenetidin does 
not influence the blood-pressure. Mah¬ 
nert considers the drug to be antago- 


240 


ACETPHENETIDIN (SAJOUS). 


nistic to strychnine in its physiological 
action, large doses producing paralysis 
of the cardiac and respiratory centers. 
In the early stage of its action, however, 
it is believed to stimulate these centers 
for a time. 

Oh the Blood.—Alterations in the 
blood are much more rarely caused by 
acetphenetidin in moderate doses than 
by acetanilide. The formation of niet- 
hemoglobin has, however, been ob¬ 
served in a few cases. According to 
Cushny, this untoward result is due to 
the action of para-amidophenol, into 
which the drug is gradually decomposed 
in the organism. Cerna and Carter 
were unable to produce methemoglobi¬ 
nemia in their experiments on animals. 

Acetphenetidin is said to have a 
slightly stimulating influence on the 
sweat-glands, which is not possessed by 
the other antipyretics. 

Elimination.—Acetphenetidin is be¬ 
lieved to be eliminated chiefly in an al¬ 
tered condition, losing its acetyl radicle 
in transit through the organism, and ap¬ 
pearing in the urine as glycuronates of 
phenetidin (Cushny). The gastric and 
pancreatic juices being without influ¬ 
ence on the drug in vitro, F. Muller be¬ 
lieves that the decomposition must oc¬ 
cur after it has been absorbed. Accord¬ 
ing to Gueorguievsky, the elimination 
by the urine begins in twenty minutes 
and proceeds rapidly. Perchloride of 
iron added to this urine causes a Bur¬ 
gundy red color to appear. Acetphe¬ 
netidin may also be eliminated in part by 
the skin, since Hirschmann not infre¬ 
quently found large numbers of crystals 
precisely similar to those of the drug 
on the skin of persons to whom it had 
been administered. 

UNTOWARD EFFECTS AND 
POISONING.—H. C. Wood states 
that no symptoms are produced by 


the therapeutic dose of this drug. 
Even large doses of it have been 
given so often without markedly un¬ 
pleasant results that, in contrast with 
acetanilide and antipyrin, it has fre¬ 
quently been described as non-toxic. 
Massive doses, however, and even mod¬ 
erate doses in certain susceptible indi¬ 
viduals, have been known to cause un¬ 
toward effects similar to those of the 
other coal-tar antipyretics. The most 
commonly observed of these have been 
profuse sweating, somnolence, lassitude, 
sometimes accompanied by nausea, ver¬ 
tigo, or chilliness. In more severe cases 
there have occurred cyanosis, beginning 
and most marked in the face, lips, and 
finger-tips, then becoming general; pros¬ 
tration, vomiting, palpitation, dyspnea, 
anxious expression, followed by col¬ 
lapse, which occasionally is fatal. The 
blood may be darkened by the forma¬ 
tion of methemoglobin. The urine has 
been found to contain blood (Kronig). 
In a case reported by Hollopeter three 
doses, of 7 grains each, of phenacetin 
sufficed to produce in a woman severe 
precordial pains, great dyspnea, general 
lividity, somewhat dilated pupils, and 
collapse, with unconsciousness; recovery 
took place after a week. Cutaneous 
eruptions, usually urticarial, are some¬ 
times caused, though less frequently 
than by antipyrin. As with acetanilide, 
the onset of the symptoms is frequently 
sudden and unexpected, the patient hav¬ 
ing previously borne repeated doses 
without harmful effect. 

A girl of 16^2 years, in good gen¬ 
eral health, but having a headache 
and feeling that she had taken cold, 
took 2 headache tablets and went to 
bed. About an hour and a half later 
her lips and face began to grow blue, 
and a physician was sent for. Re¬ 
sponding at once, he found the girl 
with pronounced cardiac weakness 


ACETPIIENETIDIN (SAJOUS). 


241 


and edema of the lungs. Before any 
remedy could be administered she 
died. The tablets she had taken, 
labeled “Danbury’s headache tablets,” 
were subsequently found on exami¬ 
nation to contain acetphenetidin. G. 
L. Tobey (Mo. Bull., State Board of 
Health of Mass., Jan., 1908). 

Of 70 cases reported by 41 observ¬ 
ers in the literature from 1887 to 
1907, 3, or 4.2 per cent., terminated 
fatally. Sixty-three of the 70 cases 
were reported during the years 1887- 
90, i.c., in the period just following 
the advent of acetphenetidin as a 
medicinal agent, when the drug'was 
used freely in asthenic as well as 
sthenic affections. The most promi¬ 
nent ill effect was general systemic 
depression, which was present in 
38.5 per cent, of the cases. In 17.1 
per cent., it amounted to actual col¬ 
lapse. Cyanosis was repoVted in 34.3 
per cent, of the cases, skin affections 
of various kinds in 30 per cent., dysp¬ 
nea in 14.3 per cent., and disturbances 
of the renal function in 10 per cent. 
Kebler, Morgan, and Rupp (U. S. 
Dept, of Agricul., Bureau of Chem¬ 
istry, Bull. No. 126, July 3, 1909). 

Treatment of Acute Poisoning.—No 
special reference to this subject having 
been found in the literature, we can only- 
recall the plan of treatment used for 
poisoning by the other coal-tar deriva¬ 
tives, the toxic effects of which are iden¬ 
tical. Stimulants to the circulation 
and respiration, such as strychnine, 
atropine, aromatic spirits of ammonia, 
ether hypodermically, and digitalis; 
saline solution by enteroclysis or hy- 
podermoclysis, etc. The application 
of heat to the body should never be 
neglected in cases of collapse. Arti¬ 
ficial respiration is always valuable, 
and inhalations of oxygen may be re¬ 
sorted to as an ultimate measure. 

CHRONIC POISONING.—While 
not as frequent as chronic acetanilide 
poisoning, chronic acetphenetidin poi¬ 
soning is nonetheless fairly common. 


The symptoms show a great similar¬ 
ity to those produced by the habitual 
use of acetanilide, consisting chiefly 
of nervous and digestive disturbances, 
a cyanotic coloration of the skin, ane¬ 
mia, and weakened heart action. 

Instances of chronic poisoning have 
been reported by several clinicians. J. S. 
Davis observed a case in a woman, pre¬ 
viously “a healthy, buxom country girl,” 
who had been addicted to the acetphene¬ 
tidin habit for about seven months, in¬ 
gesting from 15 to 20 grains dailj'. The 
habit was found out by her husband when 
her supply of the drug gave out and the 
local pharmacist also ran out of a supply 
temporarily. Violent convulsive and hys¬ 
terical seizures appeared, and continued 
until acetphenetidin had been obtained for 
her. The pulse rose to 170 and became 
feeble; respiration, 30, spasmodic; pupils 
widely dilated; pallor and cold perspira¬ 
tion. The patient had over a dozen con¬ 
vulsions and vomited freely. Examina¬ 
tion subsequent to the attack showed 
some anemia, poor complexion, weak- cir¬ 
culation, pulse 124, sleep restless and 
troubled, digestion impaired, occasional 
vertigo. 

From collective reports of cases it 
would appear that toxic manifesta¬ 
tions are somewhat less likely to de¬ 
velop when acetphenetidin is taken 
habitually than when acetanilide is 
the drug used. • 

In the replies of 400 physicians to 
a set of questions sent out by the 
Bureau of Chemistry of the U. S. 
Department of Agriculture, 112 in¬ 
stances of the acetanilide habit were 
reported, 7 of the antipyrin habit, 
and 17 of the acetphenetidin habit. 
The number of cases in which ill 
effects were observed from the use 
acetanilide was 85, from antipyrin 2, 
and from acetphenetidin 7. The 
chief symptoms observed from the 
habitual use of these drugs were: 
Nervous depression, 44 cases; cya¬ 
nosis, 27; cardiac depression, 18; ane¬ 
mia, 15; dyspnea on exertion, 8; in¬ 
somnia, 4; constipation, 3; edema, 2; 


242 


ACETPHENETIDIN (SAJOUS). 


increased headache, 2; icterus, 1; 
muscular twitchings, 1; loss of sex¬ 
ual power, 1. In 5 of the cases of 
acetphenetidin habit protracted ill 
effects were noted, as compared with 
32 instances in case of acetanilide 
and 2 instances in case of antipyrin. 
The chronic symptoms oftenest 
noted were anemia, general debility, 
nervousness, and weak and irregular 
heart action. Kebler, Morgan, and 
Rupp (U. S. Dept, of Agricul., 
Bureau of Chemistry, Bull. No. 126, 
July 3, 1909). 

Treatment of Chronic Poisoning.— 
The measures required upon with¬ 
drawal of the drug will generally com¬ 
prise the use of stimulants, saline lax¬ 
atives, and codeine.—the latter used 
with caution in amounts just sufficient 
to mitigate pain and favor sleep (v. 
Treatment of Chronic Acetanilide 
Poisoning). 

THERAPEUTICS.—As Antipy¬ 
retic.—Acetphenetidin is generally con¬ 
sidered the safest of the coal-tar an¬ 
tipyretics. Its effect in reducing tem¬ 
perature is marked; as previously stated, 
its action begins in about thirty minutes 
and reaches its maximum in three to 
four hours. According to Heusner, 1 
Gm. (15 grains) of this drug is the equal 
in antithermic power of 0.5 Gm. (7p2 
grains) of acetanilide, and 2 Gm. (30 
grains) of antipyrin. The relative 
infrequency with which it causes cya¬ 
nosis, depression, and other unpleasant 
or dangerous effects recommends its 
general use as an antipyretic in prefer¬ 
ence to the older coal-tar remedies if 
used at all. The employment of anti¬ 
pyretics other than hydrotherapy and 
other external measures is decidedly on 
the wane, however, in the hands of 
competent clinicians. 

Exception to this is probably only 
to be made where prompt reduction 
of fever is required, as in cases of hy- 


peri)yrexia; here acetanilide, whether 
used in conjunction with hydrothera- 
peutic measures or not, may prove more 
effective than acetphenetidin. It is be¬ 
lieved, however, that the effect of the 
latter drug is more lasting than that of 
acetanilide; the greater tendency of 
which to depress the circulatory and 
respiratory organs should also be re¬ 
membered. As stated abov^, however, 
the use of antipyretics in the various 
forms of fever is now deemed inadvis¬ 
able by most authorities. Moreover, 
these agents, by causing the temperature 
records to lose their characteristic fea¬ 
tures, may impair their value for diag¬ 
nostic and prognostic purposes. The 
alleged prejudicial influence, on the 
other hand, that chemical antipyretics 
have been said to exert on the sub¬ 
stances of the blood-serum that antag¬ 
onize disease has been shown not to 
exist, at least in the case of the agglu¬ 
tinating bodies of typhoid serum (Soll- 
mann). When delirium is present in 
fever, the mild narcotic action exerted 
by the coal-tar antipyretics, especially 
acetphenetidin, may prove useful. 

As an Analgesic.—Phenacetin is 
chiefly of value for the relief of pain, 
especially of pain of the neuralgic type. 
In pains due to gross inflammations or 
deep-seated distress, the result of or¬ 
ganic disease of viscera, morphine is far 
more effective than phenacetin. But 
in pains due to nervous disorders, es¬ 
pecially neuralgia and neuritis, and in 
various forms of headache, acetpheneti¬ 
din has come to be considered almost 
as a specific. In hemicrania, in head¬ 
ache due to eye-strain or insufficiency 
of certain of the extraocular muscles, in 
intercostal neuralgia, sciatica, gastral- 
gia, and in the pains of tabes dorsalis, 
acetphenetidin frequently affords con¬ 
siderable relief. 


ACETPHENETIDIN (SAJOUS). 


243 


The manner in which this drug, in 
common with other coal-tar antipyret¬ 
ics, acts in relieving headache has not 
yet been definitely ascertained. Accord¬ 
ing to Brunton, headache is associated 
with and caused by what he terms a 
“colic” of the arteries of the head, the 
peripheral vessels being contracted and 
the central vessels dilated; the drug 
would presumably give relief by over¬ 
coming this abnormal condition of the 
cephalic arteries. E. Weber has re¬ 
cently demonstrated experimentally 
in dogs whose brain had been exposed 
that coal-tar drugs cause constriction 
of the vessels on the surface of the 
cerebrum. 

It is well known, moreover, that 
caffeine, an undoubted vasoconstrictor, 
when combined with the coal-tar drugs, 
greatly assists their analgesic action in 
headaches. Hence it would seem as if 
the relief given in these cases were due, 
in some way, to a modification in the 
caliber of the vessels. 

In acute rheumatism, acetpheneti- 
din has been found useful as an anal¬ 
gesic in doses of 3 to 8 grains (0.2 to 
0.5 gram), given every four hours. A 
valuable combination is 4 grains each of 
acetphenetidin and salol, given three or 
four times daily. Eldredge counsels the 
administration of acetphenetidin in pow¬ 
der and salicylic acid in solution, the 
dose of each being regulated according 
to the patient’s susceptibility and the 
severity of the attack. In cases with 
cardiac complications, he claims not to 
have observed any depressing action on 
the heart when the drug was given to 
reduce fever. Hirschfelder noted spe¬ 
cially the fact that sometimes a hyp¬ 
notic action seemed to be produced. In 
subacute rheumatism and in lumbago 
and other rheumatic muscular pains, 
the drug is also frequently effective. 


In gonorrheal rheumatism, acetphe¬ 
netidin was found by Eldredge to act 
well when given with potassium iodide 
and sodium salicylate. 

In influenza, acetphenetidin has be¬ 
come a favorite remedy. The pains in 
the head, back, and limbs are relieved, 
and the fever reduced. The drug may 
be given alone in powder form, or com¬ 
bined with other remedies, e.g., quinine. 
In this disease, essentially an asthenic 
disorder, it is important that the anal¬ 
gesia be secured with the least possible 
degree of general depression; hence 
acetphenetidin should always be given 
the preference over its more depressing 
congeners—acetanilide and antipyrin. 

Acetphenetidin and other coal tar 
preparations have been successfully 
employed in the treatment of mi¬ 
graine and in neuralgia. Pharmaco¬ 
logists assume that these results are 
obtained by a chemical blocking of the 
nerves that mediate sensations of pain, 
said blocking taking place presumably 
in the region of the thalamus. So effi¬ 
cient have these products proved in 
wisely selected cases, that their use 
seems at present to be justifiable, des¬ 
pite their undeniable ulterior effects, 
many of which are sometimes exceed¬ 
ingly alarming and some of which have 
resulted in fatalities. In using these 
preparations it should be strictly borne 
in mind that the obvious benefits se¬ 
cured in neuralgia and migraine are pal¬ 
liative only; the drugs are in no sense 
curative, even though their power to 
give grateful alleviation may readily 
continue until the provocative cause of 
the distress has more or less completely 
disappeared. The aim should be to 
ascertain the source of the neuralgic 
toxin and eliminate it. 

One should select the less poison¬ 
ous of the several products, acetphe¬ 
netidin for example, and administer it 
in the smallest adequate doses, 0.2 to 
0.6 Gm. (3 to 10 grains) being usu¬ 
ally sufficient. A. D. Bush (N. Y. 
Med. Jour., Jan. 15, 1916). 


244 


ACETYLENE. 


In whooping-cough, acetphenetidin 
diminishes the severity and frequency 
of the paroxysms. In children, 1 or 2 
grains (0.06 to 0.013 gram), given three 
or four times daily, are generally suf¬ 
ficient. 

Chorea has also been treated with 
acetphenetidin. Like the other coal- 
tar drugs, acetphenetidin exerts a not 
inconsiderable effect on the motor func¬ 
tions and reflex action, as well as on 
general sensibility. Hence the fact that 
it sometimes proves useful in this dis¬ 
order. 

Insomnia, the result of overwork or 
general nervous excitability, may yield 
to acetphenetidin. Kiernan reported 
having seen it bring on sleep in persons 
suffering from insomnia due to simple 
exhaustion. In view of the possible 
serious depressive effects from an over¬ 
dose, the likelihood of a drug habit be¬ 
ing formed, and the fact that much 
safer and better hypnotics are available, 
it seems doubtful whether the use of 
acetphenetidin for this purpose should 
be encouraged. 

The same is probably true of the use 
of acetphenetidin in the initial stage of 
pneumonia, in which it has been em¬ 
ployed to relieve distress, bring on 
sweating, reduce fever, and favor sleep. 
If the drug is used at all, it must surely 
be withdrawn as soon as the patient 
begins to show pronounced general de¬ 
pression and signs of lowered circula¬ 
tory activity. In pleurisy acetpheneti¬ 
din has likewise been used to relieve 
the pain of the initial stage. 

The first stage of acute coryza may 
be shortened by giving a few doses of 
acetphenetidin, which will not only pro¬ 
mote sweating and lower the tempera¬ 
ture, but also relieve the unpleasant 
accompanying sensations. A powder 
containing 5 grains (0.3 gram) each of 


acetphenetidin and salol, together with 
1 grain (0.06 gram) of citrated caffeine, 
may be administered every three hours 
for 3 doses with advantage. 

In diabetes mellitus acetphenetidin, 
in common with other coal-tar drugs, 
has been prescribed, generally with but 
temporary benefit. 

Local Uses.—Acetphenetidin is 
sometimes used externally for its anal¬ 
gesic and antiseptic properties. Dusted 
in finely powdered form on the raw sur¬ 
faces of ulcerations of various kinds, it 
not only relieves pain, but favors the 
development of healthy granulations, 
thereby hastening the healing process. 
Because of its low degree of solubility 
in water, as compared with antipyrin 
and acetanilide, the likelihood of the 
absorption of a toxic amount of acet¬ 
phenetidin from open surfaces is 
somewhat less than with the above- 
mentioned agents. Nevertheless, this 
danger should always be kept in 
mind, and the external use of the drug 
confined to lesions covering a small 
area only. 

C. E. DE M. Sajous 

AND 

L. T. DE M. Sajous, 

Philadelphia. 

ACETYLENE. —When calcium car¬ 
bide (CaC 2 ) is brought in contact with 
water, acetylene gas is formed. Being 
capable, when ignited, of furnishing a de¬ 
gree of light far superior to that of ordi¬ 
nary gas, acetylene has in recent years 
been considerably used as an illuminant. 
When prepared from pure calcium carbide 
and purified by liquefaction, it has a pleas¬ 
ant ethereal odor and can be breathed in 
small quantities without giving rise to ill 
effects. Impure gas, prepared from coal 
or impure lime, may contain calcium sul¬ 
phide and phosphide, and the acetylene 
prepared from it may then have a very 
unpleasant odor. 

Acetylene Poisoning.—Acetylene may be 
fatally poisonous when present in proper- 


ACIDITY OF THE GASTRIC CONTENTS. 


245 


tions as high as 40 per cent, by volume, as 
shown by Grehant, Berthelot, and Mois- 
sant. A mixture of 20 volumes of acety¬ 
lene—prepared from calcium carbide, 20.8 
volumes of oxygen, and 59.2 volumes of 
nitrogen—was breathed by a dog for 
thirty-five minutes without any marked 
disturbance, and 100 c.c. of the blood were 
found to contain 10 c.c. of acetylene. With 
40 volumes of acetylene, the proportion of 
oxygen remaining the same, a dog died in 
less than an hour, owing to failure of the 
heart’s action, and 100 c.c. of blood con¬ 
tained 20 c.c. of acetylene. With 79 vol¬ 
umes of acetylene and 21 volumes of oxy¬ 
gen the poisonous effects were still more 
strongly marked. 

The poisonous action of acetylene itself 
is feeble when the blood is at the same 
time supplied from the air with the usual 
amount of oxygen. In other words, acety¬ 
lene inhaled in the open air is but slightly 
harmful. Brociner found that 100 volumes 
of blood dissolve about 80 volumes of 
acetylene; the solution shows no charac¬ 
teristic spectrum, and is reduced by am¬ 
monium sulphide as readily as ordinary 
arterial blood. If any compound of acety¬ 
lene and hemoglobin is formed, it is very 
unstable, and is not analogous to carboxy- 
hemoglobin. 

In a closed room, however, where the 
oxygen is not kept up to the normal stand¬ 
ard, when the accumulation of a foreign 
gas would prevent the constant renewal of 
air through window and door interstices or 
open chimneys, and where the products 
of respiration would be allowed to accu¬ 
mulate, it would quickly prove mortal 
by paralyzing the respiratory function. 
Mosso and Ottolenghi found experimen¬ 
tally that acetylene has considerable toxic 
power. One pint of the pure gas caused 
severe symptoms of poisoning in dogs, and 
even when mixed with air (20 per cent.) 
it proved fatal after an hour. If the gas 
was administered rapidly, the animal re¬ 
covered when placed in the open air, but 
if given slowly this did not occur, and the 
animals died. 

Thomas Oliver has shown that a mixture 
of air and acetylene commences to be ex¬ 
plosive when it contains 5 per cent, of 
acetylene, whereas it requires the presence 
of 8 per cent, of coal gas to make a similar 


mixture explosable. If a rabbit is placed 
in a bell-jar into which ordinary air and 
acetylene are pumped, the animal seems 
for a long period to experience very little 
inconvenience. It is not until ordinary 
atmospheric air is excluded and only acety¬ 
lene admitted that symptoms gradually 
and slowly develop. After a more length¬ 
ened exposure to acetylene than that 
which is necessary for coal gas the animal 
becomes intoxicated, it falls over on its 
side apparently profoundly asleep, and, 
while all through the experiment its 
breathing has been somewhat short and 
rapid, stupor steals over the animal ap¬ 
parently painlessly. A few inhalations of 
atmospheric air are sufficient to restore to 
the animal all its faculties. Should in¬ 
halation have been pushed further and the 
animal have been very deeply asphyxiated, 
death may ensue, cyanosis, hitherto ob¬ 
served, being rapidly replaced by extreme 
pallor. 

Treatment of Acetylene Poisoning.— 
That fresh air should at once be given the 
patient need hardly be mentioned. The 
patient should be removed from the 
poisoned atmosphere into a well-ventilated 
room and artificial respiration practised. 
Hypodermic injections of strychnine and 
digitalis should be administered while 
oxygen is sent for. This gas should be 
inhaled as soon as practicable, while arti¬ 
ficial respiration is continued with vigor, 
the patient being simultaneously rubbed. 
Rectal injections of warm coffee are also 
useful. Hypodermoclysis, with epinephrin 
or adrenalin 1: 1000 solution introduced 
drop by drop into the saline solution by 
pushing the hypodermic needle into the 
rubber pipe, is indicated in all cases of 
severe poisoning by the gas. 

In all such cases the efforts of the physi¬ 
cian should be kept up a long time, the 
respiration and pulse being unreliable 
guides as regards the presence in the sys¬ 
tem of sufficient life to render resuscitation 
possible. S. 

ACIDITY OF THE GASTRIC 
CONTENTS, TESTS FOR.— While 

the acidity of normal gastric juice is due 
mainly to the presence of hydrochloric acid, 
departures from the normal proportion of 
this acid in the gastric contents have been 


246 


ACIDITY OF THE GASTRIC CONTENTS. 


found to accompany with sufficient frequency 
certain disorders to facilitate the recognition 
of these disorders. Thus, a proportion of 
hydrochloric acid of 0.15 to 0.3 per cent, 
represents the acidity found under normal 
conditions, i.e., euchlorhydria, but an ex¬ 
cess of acid, hyperchlorhydria, is common 
in gastric ulcer, gastroptosis, hysteria, 
tabes, and other disorders. Hypochlor- 
hydria, a deficiency of hydrochloric acid, 
also accompanies various disorders, espe¬ 
cially gastric cancer, neurasthenia, anemia, 
chronic gastritis of long duration, gastric 
neuroses, and certain diseases of the pan¬ 
creas, while achlorhydria, absence of hydro¬ 
chloric acid, is found in advanced cases of 
the same disorders. Again, the fact that 
hydrochloric acid is necessary to peptic 
digestion, while acting as a powerful anti¬ 
septic to the ingested foodstuffs, further 
indicates the practical importance of ascer¬ 
taining accurately the acidity of the gastric 
contents. 

To obtain accurate information, it is 
necessary to administer a test-meal con¬ 
taining a definite quantity of foodstuffs, 
and to leave the latter in the stomach a 
definite time. 

Test-meals.—Those described are gen¬ 
erally given preference;— 

The Ewald-Boas breakfast consists of 1 
roll weighing about 35 Gm. (9 drams) and 
a large wineglass of 300 Gm. (10 ounces) 
of water. This meal should be taken early 
in the morning on an empty stomach, the 
bread being eaten slowly and the water 
sipped while this is done. At the end of 
one hour, 20 to 60 c.c. (5 to 10 drams) of 
the meal should be withdrawn from the 
stomach in the manner indicated below. 

The Leuhe-Riegel test-meal consists of 
beef soup, 400 c.c. (12 ounces); beefsteak 
finely chopped, 200 Gm. (6 ounces); wheat 
bread or potato, 50 Gm. (1.6 ounces), and 
water, 200 Gm. (6 ounces). The gastric 
contents should be removed at the end of 
four hours. 

The Salzer method includes two meals: 
The first consists of 30 Gm. (1 ounce) of 
lean roast beef chopped very fine; milk, 
250 c.c. (8 ounces); rice, 50 Gm., and 1 
soft-boiled egg. The second meal, given 
four hours later, is an Ewald-Boas break¬ 
fast, described above. At the end of five 
hours after the first meal, that is to say, 


one hour after the second, the gastric con¬ 
tents is withdrawn. 

The Salzer test affords, in addition to the 
opportunity of ascertaining acidity, that 
of determining the motility of the gastric 
muscles; for if particles of meat of the 
first meal are still present at the end of 
five hours, the propulsive activity of the 
stomach wall is deficient. 

Withdrawal of Gastric Contents.—This, 
the next step of the examination, is car¬ 
ried out with the aid of a flexible red rub¬ 
ber tube about a yard in length, the 
catheter-like end of which is provided, a 
short distance above the tip, with a fenes¬ 
tra or opening. It is an ordinary stomach 
tube the upper end of which is funnel' 
shaped. About 2 feet above this end is a 
mark which, when the tube is introduced 
sufficiently far, i.e., when its tip reaches 
the bottom of the stomach, corresponds 
with the incisor teeth of an adult. 

The patient’s clothing being protected 
with a towel tied round his or her neck, 
the tube, previously warmed by being 
placed in a bowl of warm wat r and lubri¬ 
cated with glycerin, is introduced, i.e., 
passed down the esophagus. This is done 
readily by pushing the end of the tube 
gently into the latter, over the epiglottis, 
while the patient swallows, and as often 
as he does so. In some cases, especially 
the first time, the procedure may cause 
gagging, but this can be avoided by pass¬ 
ing the tube on one side of the epiglottis, 
i.e., in either pyriform sinus. The sensi¬ 
tive surface of the pharynx is thus avoided. 

To withdraw the gastric contents several 
ways are available. ’ The easiest is to de¬ 
press the external end of the tube as soon 
as the latter is in situ, and request the pa¬ 
tient to lean forward and cough a few 
times or contract his abdominal muscles. 
An essential point, however, is that the 
(clean) bowl in which the gastric contents 
is to be collected must be considerably 
below the level of the patient’s stomach, 
i.e., between his knees, so as to obtain the 
benefit of siphonage. The expulsion of 
the gastric contents is facilitated by press¬ 
ing on the stomach while the patient is 
coughing or contracting his abdominal 
muscles; it is further aided by having him 
lie down on a lounge, the bowl being 
placed on the floor. It is not necessary to 


ACIDITY OF THE GASTRIC CONTENTS. 


247 


empty the stomach, a couple of table¬ 
spoonfuls (about 30 c.c.) sufficing for all 
purposes. 

Various pumps, aspirating bulbs, etc., 
have been invented to deplete the stomach, 
but they entail the use of parts that are 
difficult to clean properly, and expose the 
gastric mucosa to the evil effects of direct 
suction by the tube. Moreover, compli¬ 
cated instruments tend to increase the 
timidity of the patient, which, at best, is 
sometimes difficult to overcome. Briefly, 
the above-described “simple expression 
method" is, on the whole, the most satis¬ 
factory. 

Contraindications to the Use of the 
Stomach Tube.—In a certain proportion of 
cases, however, even the use of the simple 
stomach tube may prove dangerous. They 
are: cases of advanced cardiac disorder; 
advanced arteriosclerosis, especially if 
there is a history of cerebral hemorrhage 
or “slight stroke"; elderly persons of 
apoplectic build. In either of these the 
tube may cause a sudden reflex rise of the 
blood-pressure and rupture of any diseased 
vascular tissue. A history of recent hema- 
temesis or of bloody or tarry stools is 
also a contraindication, since the bleeding 
may be due to gastric ulcer or cancer, 
which the extremity of the tube might 
readily abrade, and thus cause renewal of 
the hemorrhages. Advanced tuberculosis, 
marked emphysema, pregnancy, and ex¬ 
treme debility are also recognized as con¬ 
traindications. 

Determination of Free Acids.—The mere 
presence of any free acid, hydrochloric, 
lactic, etc., can readily be determined by 
using paper previously dipped in a solu¬ 
tion of Congo red and dried. This turns 
blue in the presence of free acids, but does 
not identify one acid from another. 

To identify hydrochloric acid, the best 
reagent is probably the dimethylamidoazo- 
benzol. It may be used in 0.5 per cent, 
solution or in absorbent paper allowed to 
dry before using. The yellow color of 
either becomes reddish pink in the pres¬ 
ence of hydrochloric acid. This test fur¬ 
nishes an inkling as to the degree of 
acidity due to the latter, for the reddish- 
pink color becomes much deeper in pro¬ 
portion as the percentage of acid is great. 

Tropeolin is another good reagent which 


can be used in the same manner. Its yel¬ 
lowish-brown alcoholic solution turns red 
in the presence of both hydrochloric acid 
and lactic acid; but the former can be 
differentiated by spreading a few drops of 
a saturated solution in a porcelain dish, 
and adding thereto an equal quantity of 
the gastric fluid. On mixing them and 
heating them gent^, blue and lilac stripes 
(formed by hydrochloric acid only) appear. 

An extremely delicate test, which will 
detect 1 part of hydrochloric acid in 
20,000 parts of water, is Gunzburg’s, whose 
reagent consists of :— 

B Phloroglucin . 2Gm. (30gr.). 

Vanillin . 1 Gm. (15 gr.). 

Absolute alcohol . 30 c.c. (1 oz.). 

It should be kept in a dark bottle. By 
adding a few drops of this reagent to the 
gastric filtrate and allowing the mixture 
to evaporate to dryness, a beautiful rose- 
red tinge is obtained if free hydrochloric 
acid is present. 

To Ascertain the Total Acidity.—The 
easiest method is to add 1 drop of a 1 per 
cent, solution of phenolphthalein to 10 c.c. 
(2]A drams) of the gastric fluid, after 
filtering the latter, and neutralizing the 
mixture by a given quantity of decinormal 
solution (about 30 grains to the pint—2 
Gm. in 500 c.c. of distilled water) of 
sodium hydroxide. The technique of the 
procedure is as follows: Place 10 c.c, of 
the filtered gastric fluid in a beaker, and 
add thereto 2 drops of phenolphthalein 
solution. Then add the decinormal sodium 
hydroxide solution from a graduated bu¬ 
rette (mixing with a glass rod) until a 
permanent red or reddish-pink color ap¬ 
pears, which means complete neutraliza¬ 
tion. Now, the number of c.c. (say 4 or 
4.5) of sodium hydrate solution necessary 
to obtain the latter, as shown by the 
graduated burette, with a naught to the 
right of this figure (making 40.0 or 45.0 of 
the above figures), will represent the per¬ 
centage of total acidity. 

A watery solution of Congo red may be 
used instead of phenolphthalein. As we 
have seen, free hydrochloric acid in the 
gastric fluid or chyme changes the red 
color to blue. If, now, decinormal sodium 
hydrate solution (vide supra) is slowly 
added to the mixture until the Congo red 





248 


ACNE (STELWAGON). 


is restored, the number of cubic centi¬ 
meters of the sodium hydrate solution re¬ 
quired to obtain this result will represent 
the amount of free hydrochloric acid. 

Lactic acid, which suggests the presence 
of cancer or dilatation, being contained in 
all bakery products, in meats as sarco- 
lactic acid, sour milk, sauerkraut, and 
sour gherkins, a special meal is necessary 
to eliminate from the test the acid due to 



Strauss’s separating funnel for lactic acid test. 

foods. A bowl of soup prepared with 
Knorr’s oatmeal, rendered palatable by 
adding common salt, suffices for this pur¬ 
pose. Uffelmann’s reagent may then be 
used. It is composed as follows:— 

B Solution of carbolic acid (4 


per cent.) . 10 c.c. 

Distilled water . 20 c.c. 

Official neutral ferric chloride 
solution . 1 drop. 

This should be prepared fresh for each 
test. Its amethyst-blue color will be 
turned to canary yellow when added to 
the gastric filtrate. 


A quantitative estimation of lactic acid 
may be obtained by Strauss’s method. “A 
separating funnel (shown in the annexed 
cut) with marks at 5 c.c. and 25 c.c. is 
filled to the first mark with gastric juice 
and then to the second with ether. After 
thoroughly shaking, the fluid is allowed to 
flow out to the first mark (5 c.c.), then 
filled with water to the second mark 
(25 C.C.). Two drops of a 10 per cent, 
solution of iron chloride are then added. 
A beautiful green color appears in the 
presence of amounts exceeding 0.5 per 
mille.” (Lenhartz-Brooks.) 

Butyric acid and other fatty acids, on 
boiling the gastric filtrate, emit a charac¬ 
teristic odor. They also turn yellowish 
brown in the presence of Uffelmann’s solu¬ 
tion, just described. Another test is to 
shake the gastric product (unfiltered) with 
acid-free ether, and then allow the latter 
to evaporate. On adding calcium chloride 
to a watery solution of the residue, the 
butyric acid forms oil droplets with the 
characteristic odor of the acid. 

Acetic acid also emits a characteristic 
odor, that of vinegar. A small quantity of 
gastric filtrate, say 10 c.c., is treated with 
ether as above. The residue being dis¬ 
solved in a little water and neutralized 
with a solution of sodium carbonate, a 
couple of drops of a very dilute solution 
of ferric chloride are added. The filtrate 
then becomes dark red if acetic acid is 
present. Or a few drops of sulphuric acid 
and alcohol may be added to the same 
neutralized residue; on heating, the latter 
then gives off the characteristic vinegar¬ 
like odor of acetic acid. S. 

ACIDOSIS. See Autointoxica¬ 
tion. 

ACNE. —DEFINITION.— Acne 
is characterized by the presence, 
usually on the face, of small elevations 
or nodosities varying in size from a 
pinhead to a pea. These elevations, 
or pimples, are also present on the 
back, shoulders, and chest in many 
cases. 

SYMPTOMS. —The elevations are 
conical or hemispherical, and, as a 



















ACNE (STELWAGON). 


249 


rule, in the earliest stage of the lesion 
somewhat painful, especially upon 
pressure. In most of the lesions there 
is a distinct tendency to suppurative 
change. In the center of the lesion a 
whitish-yellow spot forms where the 
pus raises the epidermis. In from 
three to ten days, or even longer, the 
lesion breaks and a small amount of 
pus is discharged. At other times the 
pus dries to a thin crust, or occasion¬ 
ally the contents, especially in slug¬ 
gish lesions, are absorbed. A red 
elevation is left which gradually flat¬ 
tens out, leaving a brownish stain, 
which eventually disappears. The 
surrounding skin is frequently oily 
and shiny. Small, sluggish, abscess¬ 
like lesions, and tumors as large as a 
pea or a small nut, formed by reten¬ 
tion cysts of sebaceous glands, are 
sometimes seen; they may gradually 
work to the surface or may persist for 
months and finally disappear or form 
hard spherical indurations by retrac¬ 
tion and inspissation of their contents. 
Scarring, usually consisting of small, 
white, cicatricial depressions, is to be 
seen as a consequence in some cases. 
In the majority of cases, however, 
permanent marks are not left. The 
regions most afifected in acne are the 
face, shoulders, and anterior and pos¬ 
terior aspects of the shoulders. Occa¬ 
sional cases are observed in which the 
back, extending as far down as the 
sacrum, is the chief seat of the disease. 
In rare instances (acne cachecticorum, 
acne scrofulosorum, and acne medi¬ 
camentosa) the eruption may be more 
or less general. 

VARIETIES. —There are several 
varieties of lesion observed in acne, 
one kind of which is apt to predomi¬ 
nate, and this has given rise to the so- 
called varieties of the disease. 


Acne vulgaris, or acne simplex, is, by 
far, the most common clinical type. 
The lesions are usually of a mixed 
character, consisting of blackheads, 
pinhead- to pea-sized papules, papulo¬ 
pustules, and pustules. Each lesion 
may in its beginning have a small, red 
areola. There is also slight pain upon 
pressure. The lesions are rapid in 
evolution, running a course in several 
days to a week. As in all types, they 
are discrete and isolated. 

The term “acne papulosa’’ is given to 
a not uncommon type in which the 
lesions are usually small and show but 
little disposition to reach the pustular 
stage, disappearing by absorption or 
by desiccation and exfoliation. 

Acne' punctata might be termed mi¬ 
nute papular, the lesions being, for the 
most, pinhead in size, with a central 
comedo, or blackhead. 

Acne pustulosa is another type in 
which the lesions go rapidly into the 
pustular stage, the eruption appearing, 
for the most part, to be made up, 
almost entirely, of pustules. In size 
they vary from a large pinhead to a 
large-sized pea. 

Acne indurata, or “tuberculosa,” is a 
form of the eruption in which the 
lesions tend to be closely crowded 
here and there and in such places, and 
also with single lesions, the underly¬ 
ing base becomes hard, inflamed, and 
indurated, being also somewhat deep- 
seated. 

In acne phlegmonosa the inflamma¬ 
tory and suppurative process begins 
deep down in the sebaceous gland, 
forming veritable small dermic and 
intradermic abscesses, usually with 
but slight tendency to break through 
the surface. 

Acne cachecticorum characterizes an 
acneic eruption, more or less general. 


250 


ACNE (STELWAGON). 


occurring in weak, cachectic individ¬ 
uals; the lesions are livid, indolent, 
violet-red papulopustules of moderate 
and large size and of slow evolution, 
leaving, as a rule, small cicatrices. 
Acne scrofulosorum is really a variety 
of the last named,—acne cachecti- 
corum,—occurring in those of dis¬ 
tinctly strumous or tuberculous tem¬ 
perament. 

Ac7te artificuUis seu medicamentosa is 
a form of acneic eruption produced by 
the ingestion of certain drugs, as the 
iodides and bromides, and also by the 
external applications of certain reme¬ 
dies, such as tar, the paraffin oils, etc. 

“Acne atrophica^* is a name given to 
those cases of acneic eruption which 
tend to leave depressed scars'. This 
probably occurs most frequently in 
those cases in which the lesions are 
sluggishly papular or papulopustular, 
the lesions disappearing by absorption 
or crusting and leaving behind small, 
punched-out cicatrices. 

Acne hypertrophica is really the op¬ 
posite of the last-named variety, and 
occurs in about the same kind of 
cases, small, whitish, connective-tis¬ 
sue, pinpoint or small-pea sized pro¬ 
jecting hypertrophies marking the 
sites of the lesions. It is rare. 

ETIOLOGY.—Acne begins usually 
near puberty, when the pilar system is 
more actively developing, and the 
functions of the sebaceous glands like¬ 
wise ; and is more frequent among 
patients with digestive troubles, con¬ 
stipation, dilatation of the stomach, 
menstrual irregularities, the strumous 
diathesis, possibly the arthritic di¬ 
athesis, and disturbances of the nerv¬ 
ous system. 

The etiological participation of gas¬ 
trointestinal disorders in acne vul¬ 
garis are receiving due attention. 


While the acne bacillus is generally 
recognized as the direct cause of 
acne vulgaris, a number of associated 
conditions probably act as predispos¬ 
ing factors, among which gastrointes¬ 
tinal abnormalities seem of special 
importance. They investigated the 
problem in 30 cases by means of 
fluoroscopic examination of the gas¬ 
trointestinal tract, test meals, and 
analyses of the gastric contents. It 
was found that 93 per cent, showed 
gastric abnormalities and 70 per cent, 
intestinal abnormalities. The most 
common gastric findings were hyper¬ 
acidity, 48.1 per cent.; retention, 36.6 
per cent.; atony, 33.3 per cent., and 
ptosis, 40 per cent. The most com¬ 
mon intestinal findings were cecal 
stasis, 46.6 per cent.; ptosis of the 
colon, 36.6 per cent., and right lower 
quadrant adhesions, 23.3 per cent. 
Clinically, 62.3 per cent, of the cases 
gave evidence of gastric disturbances 
and 40 per cent, were constipated. 
None of the cases examined gave en¬ 
tirely normal gastrointestinal find¬ 
ings, and 60 per cent, showed abnor¬ 
malities which were of such a nature 
as to permit gastric and intestinal 
stasis, followed by toxic absorption. 
L. W. Ketron and J. H. King (Jour. 
Amer. Med. Assoc., Aug. 26, 1916). 

[The confusion concerning the patho¬ 
genesis of acne is due, in my opinion, to 
the fact that the ductless glands are over¬ 
looked in the morbid process. As I 
pointed out in 1914 before the Manhattan 
Dermatological Society of New York, a 
close relationship suggests itself when 
these structures are accepted as active 
participants in the morbid process. At 
puberty we encounter the period when 
the thymus has ceased to furnish its 
nucleins. Many of the disorders of ado¬ 
lescence may be traced to this cause. De¬ 
velopment has ceased, and the other or 
permanent ductless glands whether ready 
or not, must sustain the life process with¬ 
out the thymus. The pancreas, thyroid 
and adrenals maintain not only the nutri¬ 
tional processes of the body, oxidation and 
metabolism, but simultaneously its defen¬ 
sive process. When we realize that they 
do this while carrying out the catabolic 


ACNE (STELWAGON). 


phase of metabolism, and as a part of this 
process, breaking down poisons, toxins, 
etc., as they do normal wastes, the ap¬ 
parent complexity of the immunizing 
process disappears. Nevertheless, upon 
the integrity of these two connected func¬ 
tions depends the health of the whole. 

Many other facts submitted at the time 
suggest that acne may be due to inadequate 
defensive activity of the body through in¬ 
sufficiency, inherited or acquired, of one 
or more of the ductless glands, which not 
only from my viewpoint nowadays, but 
from that of others, take part in this gen¬ 
eral defensive process. We have indirect 
proof of deficient immunizing power as a 
cause in the effectiveness in many cases of 
acne, of staphylococcus vaccine, which 
though not specific, nevertheless provokes 
the formation of antibodies. Thyroid 
gland with pituitary or ovarian gland is 
also effective in hypothyroidism, especially 
hypothermia are discernible. 

When, as stated above, gastrointestinal 
disorders exist in the case, the result¬ 
ing autointoxication aggravates and may 
doubtless cause the disease, owing to the 
deficient antitoxic activity of the blood, 
due in turn to the deficient activity of the 
ductless glands. C. E. de M. S.] 

It has been also alleged without, 
however, substantial foundation that 
lesions of the genitourinary organs 
and venereal excesses may provoke 
the disease. Lesions may be due to 
mechanical irritation caused by the 
product of secretion remaining in the 
excretory canal or gland itself. Some 
drugs, as already stated,—such as the 
bromides and iodides,—are occa¬ 
sionally responsible for the eruption 
or an increase in an already existing 
eruption. Certain drugs applied ex¬ 
ternally may also provoke acneic 
lesions, such as tar and tar products, 
juniper oil, and the like. Workers in 
paraffin and parafifin products will not 
infrequently be found aflfected with 
papules and pustules, especially those 
of a furuncular or abscess type. The 
direct local exciting factor is thought. 


251 

by many, to be a micro-organism, 
Gilchrist’s observations pointing to 
a specific bacillus. 

PATHOLOGY.—In most cases the 
process begins by a perifolliculitis, 
which later on gives rise to a purulent 
folliculitis. It would thus seem that 
in some cases the sebaceous glands 
play but a small part in the affection. 
In most cases, however, when come¬ 
dones are present, the sebaceous gland 
itself is the starting point of the in¬ 
flammatory process. (Brocq.) 

Even when the focus of irritation is 
in the follicle, it is frequently limited 
to the sebaceous or sebaceous pilary 
canal. (E. Besnier, A. Doyon.) 

The papillae surrounding the come- 
done and the superficial layers of the 
corium are filled with blood-vessels 
full to repletion, and of exudation cells 
which are found in dilated vacuoles. 
(Kaposi.) 

If the process is very intense, the 
sebaceous gland may be entirely de¬ 
stroyed by the local inflammatory 
action, while the pilar bulba persists. 
(Kaposi.) 

The acneic process may be divided 
into two parts: 1. Closure of the 
sebaceous follicle and formation of 
comedo. 2. Suppuration, which only 
occurs in those follicles where the 
staphylococci aureus et albus have 
penetrated before the comedo formed. 

The complement fixation reactions 
tended to show the activity of colon 
bacilli in certain skin diseases, par¬ 
ticularly acne vulgaris, rosacea, and 
seborrheic dermatitis. Almost two- 
thirds of the cases of acne gave a 
positive complement fixation test 
with the Bacillus coli obtained from 
the feces of acne patients. In con¬ 
trast to this, only 15 per cent, of non- 
acneiform skin affections gave posi¬ 
tive reactions with this bacillus, and 
the non-eruptive controls which were 


252 


ACNE (STELWAGON). 


examined gave entirely negative re¬ 
sults with this organism. With a 
polyvalent antigen of strains of colon 
bacilli recovered from the feces of 
persons suffering from acne vulgaris, 
the percentage of positive reactions 
and the degree of complement ab¬ 
sorption were found to be higher 
than with the control antigens of 
colon bacilli from the feces of normal 
persons, with the sera of persons suf¬ 
fering from acne vulgaris and sebor¬ 
rheic dermatitis. Kolmer and Schani- 
berg (Jour. Cutan. Dis., xxxiv, p. 
166, 1916). 


TREATMENT.—In this connec¬ 
tion acne may be divided into (1) an 
irritable or inflammatory variety, in 
which the skin is fine and thin and 
easily irritated by stimulating applica¬ 
tions, and where general treatment is 
important on account of the close 
union between the acneic eruption 
and various constitutional disturb¬ 
ances. Local treatment should, at 
first at least, be of a mild character. 
(2) An indolent variety, where the in- 




Bacillus acnes {Hartwell and Streeter). 
Boston Medical and Surgical Journal, Dec, 16, 1909. 


DIAGNOSIS.—Acne is to be dif¬ 
ferentiated from the papular, papulo- 
pustular, and ‘pustular syphiloderms, 
and also from variola. 

Syphilis.—In the syphilitic eruption 
the distribution is more or less general, 
and more acute in its outbreak, darker 
lined, and occurring occasionally with 
special groupings and the presence of 
other symptoms of the disease. 

Variola.—In small-pox the premoni¬ 
tory constitutional symptoms, the sud¬ 
den outbreak, the uniformity of the 
lesions, and many other symptoms of 
differential character will serve to 
differentiate. 


tegument is thick, rough, and oily, with 
enlarged and obstructed gland orifices, 
and where the most energetic local ap¬ 
plications are well borne; here the local 
treatment is important. Probably 
most of the cases met with occupy a 
middle ground between these two ex¬ 
treme varieties. 

General Treatment. — Prophylactic 
measures, such as the avoidance of ex¬ 
ternal irritants, drugs and food liable 
to cause acne, such as coffee, tea, 
alcohol, pure wine, pork, veal, game too 
far gone, preserved fish, shellfish, fats, 
and cheeses. 

Any disorder of digestion must be 













ACNE (STELWAGON). 


253 


counteracted in order to avoid the con¬ 
gestion of the face following meals. 

If the tongue is much coated and 
shows prominent papillae, the following 
is recommended:— 

B Sodium bicarb . lOgrs. 

Ext. cascara sagr. liq _ 10-20 mins. 

Tinct. nux vomica . 7-10 mins. 

Peppermint water.Xo make 1 fl. oz.—M. 

Constipation should be counteracted 
by gentle aperients. Any condition 
capable of maintaining the sympathetic 
system in a state of tension—such as 
genitourinary troubles or affections of 
the nasal fossae—should be eradicated 
if possible. 

If the patient is lymphatic and has a 
good digestion, codliver oil is of value. 

Anemia or chlorosis calls for the use 
of chalybeates with arsenic. Iron often 
does harm unless its constipating effect 
is counteracted by using aperients. 
When the patient is arthritic, alkalies, 
especially alkaline waters, are indicated. 

No really specific treatment is known 
against acne, but the following have 
been recommended:— 

Sulphur alone: powder or tablets, 
or with equal parts of honey. 

Ichthyol (Unna) :— 


B Ichthyol . 1-2 drs. 

Dist. water . 5 drs. 


M. Sig.: Fifteen to 50 drops in water, 
to be taken morning and evening. 

Arsenic bromide in weak doses, %o 
grain, in acne pustulosa. (Piffard.) 

Mercurial preparations, such as 
corrosive sublimate or calomel, either 
alone or with jalap or colocynth ex¬ 
tract, have been found useful. 

Summary of treatment: Prohibit 
cakes, pies, pastries, salt meats, fish, 
and eating between meals. If anemic, 
give nourishing foods. Ferri citratis, 
3ij; magnesii sulphatis, 3v; strych- 
ninae, gr. j; syr. zingiberis, 5j; aquae, 


5iv. In obese, constipated, and slug¬ 
gish individuals: Potassium acetate, 
3v; fl. ext. of cascara sagrada, fl, 
ext. of rumex, 3iij; 1 dram in water 
half-hour before meals. Outdoor ex¬ 
ercise. Where comedones or pus¬ 
tules: Green soap, 3j; resorcin, 3j; 
salicylic acid, gr. v; rose-water oint¬ 
ment, 3ij: to be applied at night and 
washed off in morning, until fair des¬ 
quamation obtained. Lotio alba (po¬ 
tassium sulphide and zinc sulphate) 
applied at night after using hot or 
cold water; friction with towel. 
Cocks (Med. Record, Dec. 3, 1910). 

Acne vulgaris is caused principally 
by 2 factors: eating fermentable 
foods, and inability to prevent such 
foods from fermenting. Menstrua¬ 
tion, cigarette smoking, anemia, etc., 
are factors in acne through their in¬ 
fluence on digestion. The treatment 
consists in thorough mastication of. 
the food, putting the teeth in good 
order, and excluding starches and 
sugar from the diet. Antifermentive 
drugs, such as aloin 0.1 Gm, (lj4 
grains), ichthyol 10 Gm. (2y^ drams), 
licorice powder q. s., to be mixed 
and divided into 30 capsules and 1 
taken after meal, are of value. Sun¬ 
light and fresh air as well as exer¬ 
cise help a great deal. Drying and 
peeling lotions help locally. Vac¬ 
cines often control the formation of 
pus in the lesions, but cannot, in the 
writer’s opinion cure acne vulgaris. 
R. A. McDonnell (Jour. Cutan. Dis., 
Feb., 1917). 

The writer recommends in the 
treatment of acne, in addition to the 
customary local and dietetic meas¬ 
ures, suprarenal gland 5 grains (0.3 
Gm.), given 3 times a day. 

In cases showing torpidity he ad¬ 
vocates thyroid gland M grain (0.016 
Gm.), thrice daily. Ovarian and 
testicular extracts are also com¬ 
mended. Hollander (Arch, of Derm, 
and Syph., May, 1921). 

Local Treatment. — Constitutional 
treatment will rarely succeed alone, 
while in a large proportion a local treat¬ 
ment by itself will be found efficacious. 






254 


ACNE (STELWAGON). 


The condition of the skin should be 
improved so that it will no longer be a 
suitable culture ground for the bacillus. 
The follicles of the skin should be emp¬ 
tied of the colonies of bacilli. The skin 
should be constantly kept aseptic, so 
that any bacilli that escape on it will be 
killed, and no new infection of the skin 
will be possible. The first indication is 
met by attention on the patient’s general 
health by means of baths, diet, exercise, 
attention to hygiene, and lastly, drugs. 
The follicles are emptied by the use of 
the curette, the acne lancet, and the 
comedo expressor. The best local ap¬ 
plication is sulphur, preferably in the 
form of the old lotio alba, the formula 
for which is: Zinc sulphate and potas¬ 
sium sulpheret, of each, 3i-ij; rose 
water, q. s. ad 5iv. This is to be shaken 
up before using. Resorcin is also use¬ 
ful, as well as sulphur soap. The use of 
the Rontgen ray should be limited to 
intractable cases, and requires great 
caution to prevent doing harm, G. T. 
Jackson (Med. Rec., Mar. 18, 1905). 


Hot-water and alcoholic lotions 
sometimes act promptly. In mild cases 
these are applied at night with very 
hot water, either pure or combined 
with cologne water or camphorated 
alcohol. The water is gradually re¬ 
duced until pure camphorated alcohol 
or cologne water is used. Boric acid 
or borax may be added to the lotions: 
1 part to 50. 


Night and morning the skin should 
be bathed in very hot water (to re¬ 
duce the congestion), to which creolin, 
or a few drops of the following solu¬ 
tion, should be added:— 


Corrosive sublimate - grs. 

Tinct. of benzoin ....... 75 grs. 

Emulsion bitter almonds. 3675 grs. 


M. 

E. Lacour (Nord med., Aug. 15, 
1900). 


Many of the less severe forms can 
be cured by prolonged bathing in hot 
water. The water should be soft, and 
the applications to the face should be 
made with a soft bathing sponge. The 
sponge, loaded with water as hot as 


can be borne, should be applied to the 
face. The bathing should last about 
five minutes, and should be done each 
night and morning; at the same time 
moderate pressure is applied to the 
sponge. After the sponging the face 
should be dried on a soft towel without 
rubbing, and bay rum should be applied 
freely. The face should not be touched 
by the hands until the time for repeat¬ 
ing the process. W. L. Hunt (Jour, of 
Med. and Sci., Sept., 1904). 

Have patient vigorously scrub his 
face, every night before retiring, with 
green soap and hot water. After rins¬ 
ing with cold water and drying the face, 
the following paste is to be applied: 
Betanaphthol, 5 parts; precipitated 
sulphur, 25 parts; green soap and 
lanolin, of each, 35 parts. Spread this 
over the involved area and allow it to 
remain fifteen minutes to one hour, 
after which it is wiped off. Length of 
application depends on the reaction 
produced; if left on too long, the skin 
reddens, or, after greatly prolonged 
contact, the epidermis desquamates. 
This paste acts probably by causing 
an inflammation of the skin, which 
extends along the dilated follicles, 
thus inhibiting the secretion and pro¬ 
ducing shrinkage of the dilated seba¬ 
ceous glands. When the condition is 
improved, continue the applications at 
longer intervals to prevent recur¬ 
rence; also scrub face every second or 
third night. Burke (Penna. Med. 
Jour., March, 1911). 

Instead of camphorated alcohol there 
have been used with success:— 

Alcohol, 96°, saturated with boric 
acid, and alcohol with salicylic acid, 1 
to 30. The latter is strong and must be 
used with care. 

Mercurial preparations have been 
variously extolled, but in late years 
have gradually given way to other more 
valuable remedies. 

Mercurial lotions are efficacious in 
some cases, employed as follows:— 


B Corr. subl . 1 part. 

Alcohol, 90®. 100 parts. 

Dist. water or rose water ... 150 parts, 





ACNE (STELWAGON). 


255 


At first this solution is weakened 
with one-half its quantity of water; 
afterward, if no irritation has resulted, 
the water is gradually reduced until the 
solution is employed pure. 

Other mercurial preparations, in 
ointment form, such as the biniodide, 
the iodochloride, white precipitate, and 
mercurial plaster, viz.;— 

The ammoniated mercurial oint¬ 
ment, 5 grains, or 30 grains to 1 
ounce, is highly recommended by 
Stopford Taylor. 

Gordon Campbell recommends the 
following procedure:— 

The face is to be washed with water 
as hot as can be borne and some bland 
unirritating soap, and then, after care¬ 
fully drying the skin, the following 
lotion is applied once a day:— 

Hydrargyri chloridi corrosivi. 12 grs. 
Spiritus vini rectif . 6oz.—M. 

Eflfect for first few days will be to 
render condition worse; but, after this, 
the lotion prevents perforation of the 
pustules. 

External drug treatment in both 
acne vulgaris and acne rosacea is usu¬ 
ally disappointing. Sulphur is the best 
external preparation. Mechanical treat¬ 
ment, such as the use of hot water, 
soap, massage, and the dermal curette, 
is exceedingly valuable. The opsonic 
method in acne vulgaris is promising. 
Roentgen treatment of both diseases 
is the most valuable. In its certainty 
of cure and frequency of relapse it al¬ 
most approaches a specific. The tech¬ 
nique of using the X-ray, say, in acne, is 
of paramount importance. If the ray is 
properly applied there should be few, 
if any, failures and no undesirable ef¬ 
fects. Cole (Jour. Indiana State Med. 
Assoc., Mar., 1909). 

Formaldehyde, largely diluted, has 
recently been tried with success. 

Sulphur preparations are by far the 
most valuable in the external treatment 


of the disease; especially useful when 
much seborrhea exists. In a few 
patients sulphur preparations cannot be 
used, owing to the irritation caused. 
Sulphur may be employed in the fol¬ 
lowing ways:— 

Sulphur soap: with hot water, the 
suds being allowed to dry on to the 
face. 

Sulphur baths. 

Sulphur lotions: hot water with 10 
to 60 drops for every one-half glassful 
of liquid potassium polysulphide. 

An effective method of using sulphur 
is the following:— 

After washing with hot water and 
soap, the following mixture is applied 
with a camel’s hair brush :— 

R Precipitated sulphur, 

Potassium bicarbonate, 

Glycerin, 

Laurel water. 

Alcohol (60®) .of each 2 drs.—M. 

The coating is left on during night¬ 
time and washed off in the morning 
with an emulsion of almond oil, and 
the skin is covered with oxide of zinc 
or bismuth subnitrate ointment pow¬ 
dered over with fine starch. 

When the skin becomes irritated, the 
sulphur paste should be discontinued 
and the zinc ointment applied alone 
until the irritation has disappeared. 

The following are useful:— 

R Sulphate of zinc, 

Sulphuret of potassium..o{ each 1-4 drs. 

Water ..4 oz. 

R Precip. sulphur. 

Ether .of each 4 drs. 

Alcohol .to make 4 fl. oz. 

R Precip. sulphur . 2 drs. 

Gum tragacanth. 

Camphor .of each 20 grs. 

Lime water . 2 fl. oz. 

Water .. • •.to make . 4 fl. oz. 











256 


ACNE (STELWAGON). 


Both these lotions are often made 
more valuable by the addition of 2 to 
5 per cent, of resorcin. 

Sulphur ointments are usually made 
in the proportion of 1 in 10, with ben- 
zoated lard, simple cerate, vaselin, 
vaselin and lanolin, lanolin and sweet 
almond oil or olive oil, or castor oil 
and cacao butter. 

To the sulphur may be added oxide 
of zinc in equal parts; borax, 1 to 20; 
salicylic acid, 1 to 50; naphthol, 1 to 
10 or 1 to 20; resorcin or camphor, 1 
to 20 or 1 to 40. They may be per¬ 
fumed with essence of rose, bergamot, 
or balsam of Peru if desired. 

Sulphur soaps are sometimes more 
convenient. 

The following may be used :— 

Soap and precipitated sulphur, equal 
parts. 

Soap, precipitated sulphur, and lard, 
equal parts. 

Naphthol may be cautiously added 
to the first of the series. 

Among other local treatments 
recommended are the application to 
the pustules of carbolic acid, salicylic 
acid, or resorcin. An ointment of 
ichthyol, 1 to 4 or 1 to 8, is also useful. 

The following resorcin paste is 
recommended:— 


B Resorcin . 2j^-5 parts. 

Zinc oxide. 

Starch .of each 5 parts. 

Vaselin . 12j4 parts.—M. 


This paste may remain on a day and 
a night and then be removed with a 
piece of cotton. Cure is said to be 
speedy, occurring in three or five days. 
It is a strong preparation, acting with 
considerable energy in some cases. 

In slight cases of acne of the face 
the following formula is recom¬ 
mended: Eau de cologne, or 90 per 
cent, alcohol, with resorcin or sali¬ 
cylic acid, 2 to 4 per cent., or sub¬ 


limate or cyanide of mercury. After 
these lotions the skin should be 
slightly greased with lanolin, 10; 
water, 20; and rose water, 5 parts. 
The application of an aqueous solu¬ 
tion of ichthyol, 5 to 10 per cent., is 
also useful. Leredde (Bull. gen. de 
therap., 1903). 

Salicylic acid acts well in from 1 to 
2 y 2 per cent, in various ointments. 

Electrolysis has been recommended 
for the removal of the indurated 
masses left on the skin. 

In acne of the back the strongest 
applications, as a rule, are demanded. 
Of especial value in some cases is the 
liquor calcis sulphuridis (Vleminckx’s 
solution). This should be used at first 
diluted. 

Massage of the face is not to be 
commended for acne, often doing dis¬ 
tinct harm. 

The comedo is in the majority of 
cases the forerunner of the acne 
nodule and pustule. The comedo is 
best removed by a comedo extractor, 
which should have rounded edges. 
The pressure should be moderate, 
and if the comedo does not escape 
it is best to puncture with a narrow 
bistoury. This should be done by the 
physician. The papules and pustules 
are treated by lancing. When more 
active methods are not employed, it 
is of value to cover the parts with 
mercurial plaster for a few nights. 
Various useful methods have been 
devised, the main local applications 
consisting of sulphur, salicylic acid, 
resorcin, and soap. The best treat¬ 
ment, however, is the X-ray. In 
many cases irradiations will obviate 
the necessity of lancing the nodules 
and pustules. D. Lieberthal (Lancet- 
Clinic, Dec. 30, 1905). 

Before undertaking the local treat¬ 
ment of acne it is well to open the 
pustules, empty the comedones and 
sebaceous cysts, etc. These measures 
often prove satisfactory in indurated 
and rebellious acne. Some observers 





ACNE (STELWAGON). 


257 


object, however, to the use of the 
curette. 

Facial acne gives favorable results 
under treatment by a glass vacuum 
electrode excited by the Oudin reso¬ 
nator and transmitting quite a strong 
current. The bulb should be rubbed 
over the skin without breaking the 
contact, and at the same time a con¬ 
stant stream of tiny violet sparks 
should pass from parts of the bulb 
not in the closest' contact with the 
skin. The face should be somewhat 
red after an application lasting six or 
eight minutes during which the elec¬ 
trode is in constant motion. The 
writer is most strongly opposed to 
the practice of opening acne pustules, 
lie has seen faces as badly marked 
as by small-pox. It seems much bet¬ 
ter to treat the case along the'follow¬ 
ing lines: Rhubarb and soda inter¬ 
nally relieve any source of irritation, 
such as phimosis; cleanse the skin by 
vigorous washing with tar soap every 
night and then apply a soothing anti¬ 
septic salve, such as ung. zinci oxidi, 

2 ounces (62 Gm.); pulv. acidi salicyl., 

20 grains (1.3 Gm.). This treatment 
combined with that by high-frequency 
currents has enabled the author to 
permanently cure a number of cases 
of acne, vulgaris and the disagree¬ 
able and intractable acne rosacea. 
Sinclair Tousey (Amer. Jour, of Der- 
mat., Oct., 1911). 

Mild X-ray exposures of short dura¬ 
tion and low vacuum may often be 
advantageously employed, but should 
be done with great caution and as an 
aid rather than the sole measure of 
treatment. Its indiscriminate and in¬ 
judicious use is to be condemned. 

In the majority of cases repeated 
small doses of X-rays will bring 
about a satisfactory cure, even when 
all other treatments have completely 
failed. A third of a Sabouraud’s pas¬ 
tille dose repeated at the end of a 
week, and then after fourteen days, 
is the system found to agree best 
in most cases. After this it is often 

desirable to keep up the effect of the 

1—17 


rays for a considerable time, at three 
weeks’ to a month’s interval, between 
applications. Sibley (Clinical Jour., 
Apr. 29, 1914). 

Repeated small doses of the X-rays 
not strong enough to induce appre¬ 
ciable reaction in the skin, or a 
single large dose with a reaction, 
seem to be able to modify the 
sebaceous glands to such an extent 
that the tendency to acne dies out. 
This proved true in a large number 
of cases. Its efficacy is greater in 
acne spread over a larger surface, 
with numerous pustules, than in the 
less disfiguring, torpid type. Dos- 
seker (Therap. Monats., Aug., 1915). 

Dietetic measures are unnecessary. 
He removes all oil excess by pure 
alcohol cleansing of the face, the 
copious water drinking and X-ray 
5 minutes to each side once a week, 
or if erythema occurs every other 
week. Le Eevre (Ohio State Jour, of 
Med., Feb., 1917). 

The writer recommends the judici¬ 
ous use of the X-ray in acne. The 
nodular and keloidal varieties are not 
otherwise amenable to relief. Relapse 
after apparent cure by X-rays is rare. 
Should it arise it can be dealt with 
by further irradiation. Semon (Brit. 
Med. Jour., May 22, 1920). 

According to Bier, nature always 
meets a pathogenic substance with the 
same weapon, namely, hyperemia. 
This is shown either by scratching a 
sterile skin with a sterile needle or by 
infecting any organism with any irri¬ 
tating or poisonous germ, or, most 
commonly of all, by the reaction of the 
part when a small splinter is lodged in 
the skin. The object is to increase the 
local blood-supply. Bier’s method has 
been tried in acne with some success. 

Bier’s method for the treatment of 
acne consists in the application of 
dry cups to the affected region for 
one-half hour once or twice a day. 
The suction is slight, and the cup is 
removed and reapplied every one or 
two minutes. From two to five ap- 


258 


ACNE ROSACEA (STELWAGON). 


plications must be made over the 
same area before improvement is 
effected. The method does not pre¬ 
vent the appearance of new pustules, 
though they become less frequent. 
Eight cases treated by this method 
alone produced marked improvement. 
Moschowitz (Med. Rec., Jan. 13, 1906). 

Bier’s suction cups found useful. 
Applied for repeated five-minute pe¬ 
riods with three-minute intervals, 
making two to five applications at each 
seance. Sibley (Lancet, Feb. 4, 1911). 

Sir A. E. Wright’s vaccine therapy 
has also been used with success in acne. 
As this investigator explains, no attempt 
is made to supply to the patient pro¬ 
tective substances produced in the 
organism of an animal vicariously in¬ 
oculated, but the chemical machinery 
of the patient is induced to elaborate 
by its own efforts the protective secre¬ 
tion which is required for the destruc¬ 
tion of the pathogenic agent. 

Severe cases of acne often do bet¬ 
ter under vaccine treatment than 
comparatively mild ones; the most 
resistant to this treatment are usually 
those with abundant seborrhea, many 
comedones, and scanty foci of sup¬ 
puration. Vaccine treatment must be 
continued for 6 months at least, and 
long after all spots have ceased to 
appear, when diminishing doses at 
longer intervals will often prevent 
relapses and complete a cure. Sibley 
(Clinical Jour., Apr. 29, 1914). 

In Cornell University it was found 
that entering students showed 30.2 
per cent, of the freshman class suf¬ 
fered from acne vulgaris; general in 
» 17.8 per cent., and limited to the face 

in 12.2 per cent. Their treatment 
showed the superiority of well-known 
therapeutic measures over vaccine 
therapy. Indeed, T. J. Horder has 
well said: “The failures of vaccine 
therapy are probably more numerous 
than its successes.” Fox (Jour. Amer. 
Med. Assoc., June 24, 1916). 

Henry W. Stelwagon, 

Philadelphia. 


ACNE BACTERIN. See Bac¬ 
terial Vaccines. 

ACNE ROSACEA— defi¬ 
nition.—A cne rosacea is character¬ 
ized by a chronic congestion of the 
face, causing vascular dilatations; and 
by changes in the cutaneous glands and 
tissues, giving rise to seborrhea, inflam¬ 
matory acne, and hypertrophic changes. 

SYMPTOMS.—The nose and malar 
eminences are especially prone to this 
disorder. It may also' affect the fore¬ 
head, chin, the neighborhood of the alae 
nasi, the cheeks, and less commonly the 
side of the neck. In women the chin 
is occasionally invaded. 

There are three forms of acne 
rosacea. 

The first is the erythematous and 
telangiectasic. It may be characterized 
by temporary congestive spots on the 
face, showing themselves especially 
after meals and in the evening. These 
spots may be accompanied by no other 
lesion. This form is usually present in 
connection with more or less seborrhea, 
especially on the nose, which is gen¬ 
erally very oily. Again, the erythema¬ 
tous variety may be characterized by 
small vascular dilatations on the nose 
or malar eminences, which dilatations 
develop gradually, unite with one 
another, and form a network. This 
network is uniform in hue at a dis¬ 
tance, but nearby may be seen to be 
formed of congested surfaces over 
which are spread vascular dilatations. 
This degree of the erythematous form 
is almost always accompanied by sebor¬ 
rhea, enlarged nose, and dilated glan¬ 
dular orifices, especially in women 
toward the menopause and in wine- 
drinkers. 

The nose may be slightly violet 
hued and be cold to the touch. 


ACNE ROSACEA (STELWAGON). 


259 


The second form is the erythematous 
acne, or true acne rosacea. In addition 
to the erythematous and congestive 
feature, there may be found in this 
variety a true acneic and acne-like ele¬ 
ment: papules, pustules and tubercles 
or nodules. In some cases the acne ap¬ 
pears before the congestion. There 
is a congestive red base with fine 
vascular dilatations and papulopustules 
of various sizes, often resting on an 
indurated violet-red base. 

In this variety there may also be in¬ 
crease in number and size of the 
vascular dilatations, increase in size and 
depth of the acneic indurations, and 
proliferation and hypertrophy of the 
derma. 

The third form is the hypertrophic 
acne, or rhinophyma. In this variety 
the glandular orifices are much en¬ 
larged, while the glands themselves may 
be ten to fifteen times increased in size. 
The tissues around them proliferate, 
forming a variety of pachyderma. The 
nose may be red or violet hued, covered 
with enlarged orifices, greatly increased 
in size, occasionally reaching consider¬ 
able dimensions (the so-called Pfund- 
nase of the Germans). Its exterior 
may be mammillated. (Broeq.) 

Two subdivisions of this form are 
rendered necessary by the difference in 
the pathology of each. The first, 
glandular, presents an embossed aspect, 
the hypertrophy being due especially 
to hypertrophy of the pilosebaceous 
glands; the second, elephantiasic, pre¬ 
sents a smooth aspect, being due to 
chronic edema; there are also vascular 
dilatations, with sclerosis of the derma. 
(Vidal and Leloir.) 

ETIOLOGY. —Women suffer more 
than men from the erythematotelangi- 
ectasic and acneic forms. Men only suf¬ 
fer from hypertrophic acne. It usually 


appears between 30 and 40 years. 
In women, rosacea develops usually at 
from 30 to 45 years, and increases de¬ 
cidedly toward the menopause, after 
which it may recede. It may also, how¬ 
ever, develop at puberty. 

In young women and girls acne 
rosacea is frequently due to chlorosis, 
dysmenorrhea, or sterility. In some 
it recurs at each conception. 

Some authorities claim that, among 
the constitutional causes, heredity plays 
an important part. 

Cold feet, urethral and uterine dis¬ 
turbances, and constipation are also 
recorded as causes of the disease. Ex¬ 
ceptionally a factor in acne may be 
found in the mouth or teeth and be 
unilateral if the cause is one-sided 
(E. Besnier, Doyon). 

Dyspepsia, neuralgia, hemicrania, 
working with the head inclined forward, 
and disease of the nasal fossae are 
among the less frequent etiological 
factors (which affect men more than 
women), while high heat, overheated 
rooms, high wind, sea air, cold, and 
cold water are occasional causes, espe¬ 
cially in men. The disease may become 
started in people who for several years 
have indulged in excessive hydrothera- 
peutic treatment. (Kaposi.) 

Certain occupations which expose to 
heat, cold, winds, etc., such as those of 
coachman, baker, smith, fireman, glass- 
blower, may also become primary 
causes of the trouble. Indiscretion in 
diet and alcoholic beverages are well- 
known factors. According to Kaposi, 
in wine-drinkers the nose is bright red, 
in beer-drinkers it is violet, while in 
spirit-drinkers it is soft, large, and dark 
blue. 

PATHOLOGY. —The vascular dila¬ 
tations of the face have been considered 
by some authorities as due to circula- 


260 


ACNE ROSACEA (STELWAGON). 


tory troubles caused by compression of 
the veins in the cranial foramina. 

A certain paretic condition of the 
vascular walls may often be looked 
upon as a cause. (Brocq.) 

The cutaneous nerves of the region 
affected have been found normal by E. 
Besnier. According to Leloir and 
Vidal, however, there is congestion of 
the deeper venous network of the skin; 
dilatation of the same vessels and of 
the perifollicular vascular network, 
their walls being often diminished in 
thickness. There is also formation of 
new vessels. 

DIAGNOSIS.—Lupus Erythema¬ 
tosus. — The superficial, congestive 
variety shows a brighter and better 
defined redness; crusts or squamoe on 
the surface; sharper and more definite 
edges; greater sensitiveness to pressure; 
slight elevation above the surrounding 
surface. There are no papules, pustules, 
or tubercles. If any cicatrix be present, 
it is surely lupus erythematosus. 

Acne telangiectodes is an affection 
siii generis, and not identical with lupus 
follicularis disseminatus; but it is iden¬ 
tical with the acnitis of Barthelemy, 
and must be distinguished from the 
disease known as folliculitis. It pre¬ 
sents no sort of etiological relationship 
to tuberculosis, and should be separated 
from the tuberculomata and the tuber¬ 
culides. It does not take its origin in 
the sebaceous glands and, therefore, 
does not belong to acne. Pick (Archiv 
f. Dermat. u. Syphilis, Bd. Ixxii, H. 2, 
1905). 

Circumscribed Congestive Sebor¬ 
rhea.—In this disorder there is a limited 
extent of patches, shallower and more 
uniform redness, with crusts covering 
them. 

Sycosis Coccogenica.—This is al¬ 
ways an inflammatory disease of the 
hair-follicles and perifollicular tissues. 
There are numerous papules and pus¬ 


tules, each perforated by a hair, and 
often capped by a small circular scale. 
The upper lip and chin are sites of 
predilection. The affection is usually 
painful. 

Congenital adenoma sebaceum also 
has a special location: the nasogenial 
furrow, the parts around the nose, 
mouth, and chin. It presents a mam- 
millated aspect, and its predilection 
for early youth and its normal evolu¬ 
tion serve to establish its identity. 

Eczema.—Erythematous, or pustu- 
lopapular, eczema of the face may 
sometimes present diagnostic difficul¬ 
ties. In this disease, the more or less 
constant, and usually intense, itching, 
the serous or seropurulent secretion, 
and the desquamation will suffice to 
establish the diagnosis. 

Chilblains.—Changeableness of the 
lesions and pains are peculiar to this 
disorder. 

Acneiform Syphilides.—Here the 
manner in which the elements are 
grouped, the long duration of their 
evolution, their tendency to ulceration, 
and consecutive cicatrix are important. 

Rhinoscleroma.—In this disorder 
there are hard or ivory-like masses im¬ 
bedded in the nose. 

PROGNOSIS.—Acne rosacea does 
not always increase; it may remain 
stationary or even recede, especially in 
women after the menopause. 

TREATMENT. — As to general 
treatment, it is especially necessary to 
pay strict attention to the good condi¬ 
tion of the stomach and intestines, by 
appropriate measures and suitable 
diet. Purgatives are absolutely neces¬ 
sary from time to itime; laxatives 
should frequently be given and con¬ 
stipation should be avoided (Brocq). 

In many cases, especially where the 
hemoglobin percentage is low or the 


ACNE ROSACEA (STELWAGON). 


261 


bowels are sluggish and irregular, the 
use of Startin’s mixture is effective, 
the formula for which is: 

B Magnesii sulphatis . 30.0 

Fcrri sulphatis . 0,25 

Acidi sulphurici diluti _ 8.0 

Sodii chloridi . 2.0 

Infusi gentiafUF _q.s. ad 120.0 

Directions: Take a tablespoonful in 
half a gobletful of water one hour be¬ 
fore each meal, using a glass tube be¬ 
cause of the iron. If there is any 
indigestion this prescription may be al¬ 
ternated with the following;— 

Papain . 8.0 

Sodium bicarbonate, 

Charcoal .of each 16.0 

Make into 50 tablets. Directions: 
Two tablets in a wineglassful of hot 
water before each meal. 

J. Philip Kanoky (Amer. Jour, of 
Clin. Med., Aug., 1908). 

Proper circulation of lower limbs 
should be insured by adequate clothing. 
Any abnormal condition of the genito¬ 
urinary tract or of the upper respiratory 
tract, especially the nose, should be cor¬ 
rected, while anything tending to cause 
congestion of the face, such as tight 
collars or stays, should carefully be 
avoided. Sedentary intellectual work, 
especially by gaslight, frequently ag¬ 
gravates these cases. 

On the supposition that a rheumatic 
diathesis is a possible etiological factor, 
varioiis alkalies have been recom¬ 
mended, especially bicarbonate of 
soda or the various alkaline waters. 

Where the face is intermittently 
congested, quinine, ergotine, bella¬ 
donna, digitalis, and hamamelis have 
been suggested. These may be com¬ 
bined in a mixture, with or without 
the tincture of aconite-root. Vasocon- 
strictor drugs have but little influence. 

Perchloride of iron, tannin, ergot, 
and tincture of hamamelis are recom¬ 
mended by E. Besnier and A. Doyon. 

The following preparation is ex¬ 
tolled by Brocq:— 


B Quinine hydrobromidc, 

Ergotin .of each 30 grs. 

Belladonna extract . 6-12 grs. 

Lithium benzoate . 30 grs. 

Excipient and glycerin . q. s. 

Misc. For forty pills. 

Sig.; Two before each of the two prin¬ 
cipal meals. 

Rhubarb or aloes may also be added 
if necessary. 

Study of 12 cases of acne rosacea 
by the fractional method of gastric 
analysis. In 5 there was complete 
achlorhydria throughout the period of 
the meal and in 2 an extreme degree 
of hypochlorhydria. Of the remain¬ 
ing 5 cases, 1 showed no secretion 
of free hydrochloric until after 1 
hour, and 2 showed a temporary high 
peak in the curve of acidity, with an 
abrupt fall to the base line. There 
was also a tendency to rapid empty¬ 
ing, and a highly mucoid resting se¬ 
cretion, frequently of the viscid con¬ 
sistency of raw eggwhite. Dilute 
hydrochloric acid, 30 minims and up¬ 
ward, well diluted, after meals or 
during meals, yielded very satisfac¬ 
tory results. Ryle and Barber (Lan¬ 
cet, Dec. 11, 1920). 

The local therapeutic agents are 
the same as in acne vulgaris; though 
some irritable varieties of acne rosa¬ 
cea exist, it is usually necessary to act 
with greater energy. 

Hot water and mercurial prepara¬ 
tions are often of value. Mercurials 
are, however, much inferior to the 
sulphur preparations. 

The following has been employed 
by Bazin with success:— 


B Mercury biniodide . 7E»-15 grs. 

Lard . 1 oz.—M. 


Sulphur preparations, as already 
stated, are, however, the most useful, 
those commonly employed in acne be¬ 
ing prescribed. 

In cases of average intensity derma¬ 
tologists frequently employ Vlem- 
inckx’s solution, at first with 5 parts 
of water, then gradually making it 












262 


ACNE ROSACEA (STELWAGON). 


stronger until it is used pure. It 
should be left on several minutes, and 
followed by very hot water; it may 
often be left on overnight with advan¬ 
tage. 

Green soap gives the best results in 
obstinate acne rosacea, alone or when 
used in conjunction with sulphur, 
naphthol, or salicylic acid. It may be 
used as in acne vulgaris or spread on 
a piece of flannel; the latter is then cut 
out to fit the affected region, and left 
on as long as possible. It should not 
be left on too long. When the irrita¬ 
tion becomes too great, the application 
should cease and cooling prepara¬ 
tions, such as the following, be used: 

Salicylic acid . 7 grs. 

Zinc oxide. 

Bismuth subnitrate .. of each 30 grs 

Lycopodium . ^ dr. 

Vaselin . 2 drs. 

Lanolin . 3 drs. 

Ichthyol does not seem to be as effi¬ 
cacious in acne rosacea as in some 
other varieties of acne. (Brocq.) 

Unna recommends daily doses of 7^^ 
grains of ichthyol internally and lo¬ 
tions with ichthyol dissolved in water, 
washing with ichthyol soap. Steam 
or sulphur-water douches have also 
been used with good results. 

A solution of iodine in glycerin, ap¬ 
plied twice daily during three or four 
days, is recommended by Kaposi for 
the more severe forms, but it is dis¬ 
figuring and not advisable for patients 
outside of hospital wards. 

In a series of cases of acne rosacea 
the author succeeded in gradually re¬ 
moving the eruption by means of 
painting with undiluted iron chloride. 
The applications were repeated every 
morning and evening, and resulted in 
a complete cure. A somewhat solid 
crust is apt to form at the end of 
four or five days, and the paintings 
should be omitted until this crust is 


cast off spontaneously. When there 
is much tension the surface may be 
covered with a clean rag that has 
been thickly spread with Wilson’s 
salve or some other suitable oint¬ 
ment. In the presence of severe in¬ 
flammation an ice-bag may be applied. 
As a rule, frequent interruptions are 
unavoidable, and the treatment is 
therefore likely to last about three 
or four months. Zeissl (Munch, med. 
Woch., Nu. 20, 1908). 

Surgical treatment in this disease is 
the most efficacious. (Brocq.) 

Electrolysis is another satisfactory 
method. A fine platinum needle is in¬ 
serted alongside of the vessel, and, if 
possible, into it, and connected with the 
negative pole, while the patient holds 
in his hand a cylinder in communica¬ 
tion with the positive pole. A large 
eschar must be avoided. (Hardaway.) 

Electrolysis of each dilated sebace¬ 
ous follicle with a negative platinum 
needle and a current of from 4 to 6 
milliamperes is an effective, though 
tedious, measure. The needle should 
be moved around in the follicle in or¬ 
der to thoroughly destroy it. 

In the early stages of acne hyper- 
trophica, diet, a local spray of sulphur 
lotion, and electrolysis of the en¬ 
larged sebaceous glands are sufficient. 
But when hypertrophy occurs, with 
deformity and tumors of the nose, 
surgical measures only are satisfac¬ 
tory. The author prefers thermo¬ 
cautery to the knife, and considers 
grafting undesirable if this is used. 
When it is, however, skin grafting 
may hasten recovery and prevent 
scar contraction. Dubreuilh (Ann. de 
Derm, et de Syph., Nov., 1903). 

The ordinary galvanic or faradic 
currents have been recommended by 
Cheadle and Piffard. 

Scarification was formerly a favorite 
method. The best instrument is Vidal’s 
ordinary scarificator. The skin is cut 
obliquely or perpendicularly to the 






ACOIN. 


ACONITE (SAJOUS). 


263 


vessels, then slightly obliquely across 
these so as to form lozenges, and as 
near together as possible (from 1 to 
mm. apart), and not deep enough 
to penetrate entirely through the der¬ 
mis, so as to avoid cicatrices. 

An hour afterward the part is washed 
with a corrosive sublimate solution, 
1: 1000; then in the evening or the fol¬ 
lowing day compresses dipped into 
an ammonium hydrochlorate solution, 
1: 100, or corrosive sublimate, 1: 500, 
are applied. If too strong, warm water 
is to be added. If the reaction is too 
violent, starch poultices, bland poma¬ 
tums, or zinc oxide plasters can be 
employed. 

The treatment should be renewed in 
from five to eight days. Amelioration 
will occur in from eight to ten sessions, 
and marked improvement in from 
fifteen to twenty-five sessions. 

Scarifying should be begun in the 
lower part of the region to be oper¬ 
ated upon, in order not to be troubled 
by the blood covering the surface, ac¬ 
cording to E. Besnier and likewise A. 
Doyon. 

In the early stage of hypertrophic 
acne the scarification must be made 
deeper, and in many cases it is essential 
to also cauterize the glands deeply. 

In the advanced hypertrophic form 
direct removal with the knife is the 
best procedure. (Brocq.) 

Hypodermic injections of alcohol 
have recently been recommended. 
Phototherapy has likewise given sat¬ 
isfactory results; both high-frequency 
current and the X-ray are of value in 
some cases. 

Henry W. Stelwagon, 

Philadelphia. 

ACNE VACCINE. See Bac¬ 
terial Vaccines. 


ACOIN, a synthetic compound used 
as local anesthetic, especially in dental 
and ophthalmic practice. It is designated 
as alkyloxyphenylguanidin and occurs as 
a white crystalline powder, readily solu¬ 
ble in pure cold water to the extent of 
6 per cent., and in alcohol. 

A 1:200 aqueous solution injected under 
the skin causes a local anesthesia lasting 
about one hour. Acoin presents the draw¬ 
back, however, of being quite unstable, 
while producing greater irritation than 
cocaine, and is liable to produce necrosis. 

S. 

ACONITE. —The preparations of 
aconite usually employed are obtained 
from the root of the Aconitiim napcllus 
(monkshood, wolfsbane), a conical 
tuber greatly resembling horse-radish. 
This resemblance has caused many 
deaths. Aconite-root is, however, 
brown in color, and when scraped does 
not emit the pungent odor peculiar to 
horse-radish. Again, instead of irri¬ 
tating the palate, as does horse-radish, 
aconite-root, when masticated, soon 
produces in the mouth a sense of 
warmth and tingling, soon followed by 
local numbness varying in duration ac¬ 
cording to the length of time the 
mucous membrane is exposed to the ef¬ 
fects of the drug. Aconite owes its 
activity mainly to the alkaloid aconitine, 
of which the dried root is officially re¬ 
quired to contain 0.5 per cent. 

PREPARATIONS AND DOSE.— 
Aconite in substance is not employed, 
and the preparations made with the 
leaves are no longer official. 

The tincture (tinctiira aconiti, 1916 
U. S. P.) is no longer stronger than 
the English or French tinctures. It is 
a 10 per cent, tincture, i.e., it contains 
10 Gm. of the drug in 100 c.c. Dose, 
3 to 10 minims, every three hours. Its 
effects should be closely watched, 
especially in anemic and corpulent indi¬ 
viduals and in those addicted to alcohol. 


264 


ACONITE (SAJOUS). 


The extract (extractum aconiti, U. S. 
P.), % to % grain, is also official, and 
likewise: 

The fluidextract {fluidextractum aco- 
niti, U. S. P.), p 2 to 1 minim. 

The alkaloid aconitine {aconitina, 
U. S. R), %oo gi*ain to %oo grain (0.1 
to 0.2 mg.), occurs in the form of col¬ 
orless tabular crystals slightly soluble 
in water, but soluble in alcohol, ether, 
and chloroform. 

Aconitine is a very active poison and 
causes the responsibility of the physi¬ 
cian to be involved to a greater degree 
than any other toxic. Its activity is 
markedly increased when it is adminis¬ 
tered hypodermically, and the injections 
are very painful. These facts and the 
variations in strength of the various 
aconitines on the market have militated 
against its use, and it is best to utilize 
the other preparations, all of which 
owe their activity to aconitine. 

MODES OF ADMINISTRATION. 
—Internally aconite is usually better 
given in small and frequently repeated 
doses than in large doses at longer in¬ 
tervals. Thus the tincture may be 
given in 1 minim doses every hour until 
the desired effect has appeared or until 
distinct depression of the circulation 
indicates cessation of the drug. Aconite 
should be administered well diluted. 
In fever a dram of a mixture of 10 
minims of the tincture in 4 ounces of 
water may be given every fifteen or 
twenty minutes. For the relief of pain, 

5 minims may be administered as the 
first dose, smaller ones being then given 
at short intervals. For cardiac over¬ 
activity, doses of 2 to 5 minims (0.12 
to 0.30 c.c.) may be given thrice daily. 
When aconite is used over a long 
period, a gradual increase in its action 
is observed. Even where indicated, 
aconite should not be given freely with 


the intention of producing powerful 
effects, as its action in large doses is 
sometimes unexpectedly severe. 

Aconite may be administered inter¬ 
nally in granules, in tablets or tablet 
triturates such as are official in the 
N. F., or in solution in water (1 in 
3200). Tison has used aconite nitrate 
dissolved in a mixture of distilled 
water, alcohol and glycerin, 1 minim 
of the solution containing %2oo grain 
of the salt. As stated above the alk¬ 
aloid should be employed with great 
caution, as individual intolerance of it 
has been repeatedly observed; a third 
dose of % 3 o grain (0.5 mg.) has been 
known to cause death (Lepine). Doses 
of Ksoo grain (0.1 mg.) may be given 
every two or three hours, the drug 
being stopped when the first signs of 
toxic action appear; these are, accord¬ 
ing to Gubler: prickling of the tongue, 
a sensation of shrinkage in the face, 
and loss of elasticity of the muscular 
openings in this region. These are 
followed by general numbness and 
chilliness. A total amount of %oo to 
%5 grain (0.66 to 1.0 mg.) in twenty- 
four hours may be considered the 
limit of safety. Dujardin-Beaumetz 
advised never to give aconitine unless 
its effects can be carefully watched. 

LOCAL USE. —Aconite is used 
locally in neuralgia and skin affections, 
the tincture sometimes diluted with 
alcohol, or the linimentum aconiti et 
chloroformi of the N. F. (fluidext. 
aconit. 4.5, chloroform 12.5, in alcohol 
100), being applied. The alkaloid is 
also sometimes used in a 2 per cent, 
ointment or in the oleatum aconitinae, 
N. F. (2 per cent), but should never 
be applied to abraded areas. Undi¬ 
luted aconitine is absorbed through 
both mucous membranes and skin to 
a considerable extent. 


ACONITE (SAJOUS). 


265 


Subcutaneous injections of aconi¬ 
tine have been given for neuralgia, 
but the pain caused and the danger 
from prompt toxic effects are marked 
disadvantages. 

INCOMPATIBILITIES.— The al¬ 
kaloid aconitine in solution (1 to 3200 
being saturated) is incompatible with 
tannic acid, gallic acid, mercurials, 
and Lugol’s solution; aconitine nitrate 
is precipitated as the alkaloid by alk¬ 
alies. Among the physiological in¬ 
compatibilities of aconite may be men¬ 
tioned digitalis, atropine, strychnine, 
strophanthus, ammonia and alcohol. 

CONTRAINDICATIONS. — By 
reason of its depressant action aco¬ 
nite is contraindicated in all cases in 
which prostration exists or threatens. 
If the respiration is embarrassed; if 
the heart is in asystole; if the patient 
is depressed, recourse must be had to 
tonics and stimulants. In broncho¬ 
pneumonia, pneumonia after the pri¬ 
mary stage, typhoid fever, phthisis, 
valvular affections of the heart, and in 
all cases of collapse occurring in acute 
infectious diseases, aconite is particu¬ 
larly contraindicated. In no case where 
the heart is weakened or degenerated 
should the use of aconite be considered. 
Old age contraindicates its use to 
lower the blood-pressure in nephritis. 

PHYSIOLOGICAL ACTION.— 
Within half an hour after its adminis¬ 
tration, aconite commences to affect 
the general system, slowing and weak¬ 
ening the heart’s action, lowering arte¬ 
rial tension, increasing the action of the 
skin and kidneys, and producing more 
or less muscular weakness in propor¬ 
tion to the amount taken. It causes a 
tingling sensation in the lips, extremi¬ 
ties, and, perhaps, the whole body; it 
diminishes the rapidity and depth of 
the respiration, and causes disorders of 


vision, vertigo, and loss of tactile sensi¬ 
bility and sense of pain. The effects of 
a therapeutic dose last three or four 
hours. 

Aconite, when administered in suffi¬ 
cient dose, is a powerful depressant of 
the sensory nerve; some have believed 
that the stage of nerve paralysis is 
preceded by one of nerve stimulation, 
but Wood considers this doubtful. The 
drug paralyzes first the sensory end- 
organs, next the nerve-trunks, and 
finally the centers of sensation in the 
cord. The reflexes are correspondingly 
impaired. The power of voluntary 
movement, which continues after the 
cessation of the reflex functions, is 
finally lost, owing to the later action on 
the motor centers of the cord, and sub¬ 
sequently on the nerve-trunks. The 
brain is practically unaffected by 
aconite. 

Laborde and Duquesnel state that 
aconite in therapeutic doses has a 
particular effect in modifying special 
sensibility in the area of the trigeminal; 
they believe this effect to be exerted on 
the bulbar receptive nuclei of the nerve. 
According to Cushny, the subjective 
sensory phenomena resulting from the 
use of aconitine are due to a marked 
primary stimulation and secondary de¬ 
pression of the sensory end-organs, 
tingling and wannth locally being fol¬ 
lowed by numbness when the drug is 
applied to the skin or taken by the 
mouth. 

According to Cash and Dunstan py- 
raconitine, obtained from aconitine by 
heating to separate a molecule of acetic 
acid, causes no tingling of the lips or 
tongue. It causes slowing of the heart, 
partly from vagus irritation, partly 
from depression in function of in¬ 
trinsic rhythmical and motor mechan¬ 
isms. After its administration activity 


266 


ACONITE (SAJOUS). 


of respiration is reduced (by central de¬ 
pression) to a degree incompatible with 
life. Neither muscular nor intramus¬ 
cular nervous tissue is strongly influ¬ 
enced by pyraconitine, but the spinal 
cord is impaired in its reflex function, 
and there is a curious condition of ex¬ 
aggerated motility. 

When aconite is applied directly to 
the heart, the number and force of the 
beats are lessened, and its action is 
finally arrested in diastole. It lowers 
the blood-pressure and pulse-rate when 
given internally by a direct depressant 
action on the heart itself, and also by 
stimulating the cardioinhibitory center. 
Laborde found, however, that the con¬ 
tractility of the cardiac muscle-fiber 
itself was not directly modified by 
aconitine. 

Hare has called attention to the 
fact that the fall in pulse-rate from 
poisonous doses is sometimes preceded 
by a quickening due to a condition of 
weakness and abortive cardiac action. 
The stage of low pulse-rate is also fol¬ 
lowed by one in which the pulse is fre¬ 
quent and irregular. Upon the vaso¬ 
motor center aconite is believed by 
Cash and Dunstan to have a late depres¬ 
sant effect. It also causes slowing of 
the respiration, with lengthening of the 
expiratory period, by depressing power¬ 
fully the respiratory center. According 
to some observers, small amounts of 
the drug produce, instead, stimulation 
of the respiratory function, while 
Cushny is of the opinion that aconitine 
has a primary fexciting effect on most 
of the medullary centers—vagal, vaso¬ 
motor, respiratory—as well as the 
spinal motor centers. 

Aconite reduces the temperature both 
in health and in febrile conditions, 
probably through an action on the 
nervous heat-regulating mechanism, 


and by the circulatory depression it 
causes. It also increases the action of 
the skin, kidneys, and salivary glands. 
Increase of the gastrointestinal and 
biliary secretions is stated to have oc¬ 
curred. (Schroff, Rabuteau.) 

MODE OF ELIMINATION.— 
Aconite is excreted mainly by the uri¬ 
nary organs, though it has also been de¬ 
tected in small amounts in the saliva 
and the bile. 

ACONITE POISONING. — The 

symptoms following the ingestion of a 
poisonous dose usually show them¬ 
selves after a few minutes. The 
characteristic tingling, prickling,, and 
subsequent numbness already mentioned 
rapidly extend from the mouth and 
fauces to the face, thence to the body 
and extremities. Great prostration and 
muscular impotency follow. Speaking 
requires marked effort. The skin be¬ 
comes cold and clammy, the perspira¬ 
tion covering the surface, and the 
tissues communicating to the hand an 
icy coldness. Muscular pains may be 
present in the early stages, especially in 
the face. There is often experienced 
marked epigastric pain with nausea and 
vomiting. Later on the nausea ceases, 
owing to paralysis of the stomach walls. 

The heart-beats are greatly reduced 
in number and power. The pulse is 
usually irregular, compressible, slow, 
and so weak, at times, as hardly to be 
palpable; in the advanced stages, how¬ 
ever, it becomes abnonnally frequent. 
The breathing is labored, irregular, and 
shallow, the number of respirations 
being at first decreased, then increased. 
Cyanosis may appear. The tempera¬ 
ture is lowered, sometimes considerably. 

The pupils may become dilated or 
remain of normal size and react equally; 
occasionally they are contracted. Ac¬ 
cording to Manquat, they undergo fre- 


ACONITE (SAJOUS). 


267 


qiient variations in size at first, then 
dilate. The eyes may protrude or be 
shrunken; therefore they afiford no dif¬ 
ferential information as to the nature 
of the dmg used. 

The mind is usually clear, and the 
patient calm, though apprehensive of 
impending death. Disturbances of 
vision (diplopia, amblyopia) and of 
hearing (tinnitus, deafness), as well 
as vertigo, are frequently complained 
of. Occasionally epileptoid convulsions 
occur. Spasmodic purging, with rectal 
tenesmus and bloody stools, is occa¬ 
sionally present. 

Aconite causes paralysis of respira¬ 
tion and circulation, death being due to 
sudden arrest of the heart in diastole. 

Cases of criminal poisoning by 
aconite are rare, according to Magill. 
In the Condon case, of Springfield, 
Mass., the defendant purchased a two- 
ounce bottle of tincture of aconite, one- 
half of which was placed in a pint 
bottle of port wine and sent to the per¬ 
son whose life was attempted, and who 
drank nearly one-half of the wine. 
The immediate effect was dizziness, in¬ 
ability to move, and a peculiar creeping 
sensation in the muscles. The vision 
became obscure. Life was only saved 
by three hours of untiring efforts. 

Case of aconite poisoning in a 
woman aged 45 years, a multipara, 
who had suffered from rheumatism, 
shortness of breath, and swollen 
feet. She drank by mistake about 3 
ounces of a liniment. At once she 
recognized her mistake and experi¬ 
enced a hot tingling in the mouth, 
then numbness, giddiness, gastric 
pains, and soon thereafter followed 
by collapse. A druggist gave ipeca¬ 
cuanha wine and a strong emetic. 
Sickness continued, and a violent at¬ 
tack of clonic convulsions super¬ 
vened. 

The medical man called in found 
the patient si)eechless, cold, pale. 


skin moist, pulseless, respirations 
very faint and irregular, and the 
pupils dilated and insensitive, but no 
ptosis. The temperature was 96.6° 
F. Terrible gastric and abdominal 
pains and violent irritation and prick¬ 
ling of the skin were succeeded by 
numbness. Three times after at¬ 
tacks of clonic convulsions she ap¬ 
peared dead, but when they ceased 
the mind was clear and unaffected. 
As a cardiac depressant, ipecacuanha 
had been given; a mustard emetic 
was now administered to save the en¬ 
feebled heart. The head was kept 
low, the feet were raised, a sinapism 
was placed over the heart, and hot 
bottles and flannels were applied to 
the lower extremities and abdomen. 
Strychnine and digitalis were given 
hypodermically, and brandy was in¬ 
jected per rectum. Artificial respira¬ 
tion was unceasingly kept up. After 
an anxious six hours the breathing* 
became stronger, an irregular, inter¬ 
mitting pulse could be felt at the 
wrist, while the body warmth slowly 
returned. A little coffee and brandy 
were swallowed and retained. The 
crisis passed, and she recovered. 
The quantity of aconite taken may be 
roughly estimated as sufficient to 
kill 6 persons. Tnglis (Lancet, Jan. 
21, 1911). 

Death occurs in from one-half to five 
and half hours, the average being, ac¬ 
cording to Reichert, three and one-third 
hours. 

The symptoms resulting from a 
poisonous dose of the alkaloid aconi¬ 
tine are the same as mentioned above, 
but they occur more rapidly; hypoder¬ 
mically administered, aconitine may 
cause death in less than a minute. 

Treatment of Aconite Poisoning.— 
Death in these cases usually follows 
exertion by the patient. He should, 
therefore, be kept perfectly motionless 
in the recumbent position, even during 
emesis, his head being slightly turned 
and the dejections received on a towel. 


268 


ACONITE (SAJOUS). 


An important feature of the treatment 
is to keep the patient as warm as pos- 
si1)le by means of warm blankets and 
hot-water bottles, taking- care not to 
place the latter against the skin. The 
head should also be kept warm. If the 
patient is seen early the stomach-tube 
should be used at once to empty the 
stomach. If no stomach-tube be at 
hand, apomorphine, to % grain, 
should be administered hypodermically, 
or some other active emetic, such as 
zinc sulphate, 15 to 30 grains, be given 
by the mouth. 

Digitalis, sulphate of strychnine, and 
belladonna are the most effective rem¬ 
edies, but ether and ammonia should 
first be employed, owing to their great 
diffusibility. All these remedies should 
•be used hypodermically, the stomach 
being unable to perform its functions. 
A dram of ether, ammonia,.brandy, or 
whisky should at once be injected, and, 
after a few minutes, tincture of digi¬ 
talis, 15 minims; strychnine sulphate, 
Yoq grain; or tincture of belladonna, 10 
minims, according to what the practi¬ 
tioner may have. Atropine has been 
recommended as the most powerful 
antagonist to the depressing effects of 
aconite on the circulation and respira¬ 
tion. The dosage should be regulated 
so as to reach the point of physiological 
action by frequently repeated doses. 
Nitrite of amyl may be given by in¬ 
halation, and warm, very strong cof¬ 
fee be injected into the rectum. 

Case illustrating the physiologic 
antagonism between aconite and bel¬ 
ladonna. The patient had taken by 
mistake half an ounce of a liniment 
composed of chloroform, aconite, and 
belladonna. This means 53.3 grains 
of aconite root, which represents ^ 
grain of aconitine, of which lio grain 
has been known to be fatal. He also 
swallowed 40 minims of fluidextract 
of belladonna (B. P.), which is equal 


to 0.3 grain of the total alkaloids. 
This would represent, approximately, 
thirty times the official dose of atro¬ 
pine. Of chloroform he took 40 
minims, about eight times the official 
dose. The interest in the case lies 
in the fact that the lethal effect of a 
large dose of aconite was abolished 
by the simultaneous action of a large 
dose of belladonna. Muscular weak¬ 
ness, numbness of the extremities, 
and tendency to complete collapse 
were the only purely aconite symp¬ 
toms observed. Salivation, which is 
usually present in aconite poisoning, 
was absent, and the usually con¬ 
tracted pupil was overcome by the 
action of the atropine. Finally, the 
intensely depressant action of aconite 
on the central nervous system was 
counteracted by the stimulating in¬ 
fluence of the belladonna. The ob¬ 
vious lesson to be drawn from the 
case is the great value which should 
be attached to hypodermic injections 
of atropine in aconite poisoning. Speirs 
(Brit. Med. Jour., Aug. 15, 1908). 

Tannic acid is useful as an antidote. 
Wood recommends that it be followed 
by an emetic and cathartic to avoid the 
effects of resolution of the poison by 
the digestive fluids. 

If the patient is seen when the stage 
of depression has begun through ab¬ 
sorption of the poison, the stomach- 
pump, gently used, is alone permis¬ 
sible, emetics at this stage being liable 
to cause arrest of the heart’s action. 
Tincture of digitalis, in 20-minim 
doses, should be injected hypodermi¬ 
cally and repeated as required, besides 
the other measures indicated. Fric¬ 
tions under cover, the rubbing being 
directed over the heart, serve a useful 
purpose. Artificial respiration is of 
marked benefit and should be used per¬ 
sistently as long as any indication 
exists. 

Since the strength of the tincture has 
been decreased (U. S. P. 1905), the 
cases of poisoning have been greatly 


ACONITE (SAJOUS). 


269 


reduced, and are seldom in fact met 
with in literature. Hence the fact that 
practically all the instances recorded 
in these pages antedate the year of the 
last Pharmacopoeia. 

Series of cases, 6 of which were fatal, 
found in the literature of ten years:— 

Case 1. Tincture, 7 drams. Recov¬ 
ery. Emetics; morphine, grain ; fluid- 
extract of digitalis, 6 drops; strych¬ 
nine sulphate, Moo grain; brandy, 1 
ounce; all hypodermically. By the 
mouth, 2 gallons of warm water; fluid- 
extract of digitalis, 20 drops; coffee, 
11 pints; whisky, 3 pints; extract of 
nux vomica, % fluidram; port wine, ^2 
pint. P. F. Brick (Jour. Amer. Med. 
Assoc., vol. viii, p. 567, 1887). 

Case 2. About 8 drops of concen¬ 
trated fluidextract. Recovery. Emet¬ 
ics, coffee, whisky (dessertspoonful). 
Heat. Friction and sinapism. T. H. 
P. Baker (Amer. Pract. and News, 
vol. iv, N. S., p. 122, 1887). 

Case 3. Fleming’s tincture, V/2 
ounces. Recovery. Emetics, brandy, 
ether, digitalis, ammonia carbonate. 
Amyl nitrite and warmth. C. C. Brad¬ 
ley (N. Y. Med. Record, vol. xxxii, p. 
155, 1887). 

Case 4. Tincture, F 2 ounce. Recov¬ 
ery. Brandy by mouth and hypoder¬ 
mically. Ether. One quart of cold, 
black coffee. Heat and posture. S. 
Barnett (N. Y. Med. Record, vol. 
xxxii, p. 761, 1887). 

Case 5. Amount not known. Pa¬ 
tient intoxicated at the time. Symp¬ 
toms of acute poisoning. Recovery. 
Emetics, brandy, ammonia, and digi¬ 
talis by the mouth. Sixty minims of 
tincture of digitalis hypodermically. 
Heat. Clara T. Dercum (Med. and 
Surg. Reporter, vol. Ixi, p. 1889). 

Case 6. Tincture, amount not 
known. Child, 16 months. Marked 
toxic symptoms. Recovery. Brandy 
and fluidextract of digitalis frequently 
repeated in spite of vomiting. Byron 
F. Dawson (Med. and Surg. Reporter, 
vol. Ixii, p. 7, 1890). 

Case 7. Tincture, 2 drams. Death. 
Benjamin Edson (N. Y. Med. Record, 
vol. xxxviii, p. 365, 1890). 


Cases 8, 9, and 10. Dr. Edson men¬ 
tions certain other cases known of, 
but not treated by him, three of 
which died. 

The amounts taken in these were 
from 1 to 4 drams. 

Case 11. Tincture (B. P.), 1 ounce. 
Death in sixty-five minutes. Mus¬ 
tard, lavage, heat, ether, and brandy 
subcutaneously. L. M. Whannel 
(Brit. Med. Jour., vol. ii, p. 791, 1890). 

Case 12. Fleming’s tincture, 1 dram. 
Recovery. Sulphate of zinc, tincture 
of digitalis, 20 minims hypodermic¬ 
ally. Whisky, 1 ounce, by the mouth, 
followed by calomel, 8 grains. L. M. 
Whannel (Brit. Med. Jour., vol. ii, p. 
791, 1890). 

Case 13. Fleming’s tincture, 1 tea¬ 
spoonful. Recovery. Mustard, spirit 
of ammonia comp. (B. P.), tincture of 
belladonna, brandy. T. F. H. Smith 
(Brit. Med. Jour., vol. i, p. 1109, 1893). 

Case 14. Fluidextract, 4 drams. 
Recovery. Emetics, atropine, and 
brandy subcutaneously. Altenloh 
(N. Y. Med. Jour., vol. Ixvii, p. 358, 
1893). 

Case 15. Tincture, 7H drams. Re¬ 
covery. Mustard, digitalis, and brandy 
subcutaneously; digitalis, nux vomica, 
and brandy by rectum; ether and am¬ 
monia by inhalation; brandy and am¬ 
monia carbonate by mouth later. G. 
H. Tuttle (Boston Med. and Surg. 
Jour., vol. XXV, p. 678, 1891). 

Case 16. Mentioned by, but not 
seen by. Dr. Tuttle. Tincture, 5j/4 
drams. Death. G. H. Tuttle (Bos¬ 
ton Med. and Surg. Jour., vol. xxv, p. 
678, 1891). 

Case 17. Preparation not noted. 
Four teaspoonfuls. Recovery. Sul¬ 
phate of copper, digitalis, wine by 
mouth; whisky by rectum; whisky, 
Hr> grain strychnine, and digitalin, 
grain, hypodermically. Warriner (N. 
Y. Med. Record, vol. xxxix, p. 521, 
1891). 

Case 18. Tincture, 2 drams. Recov¬ 
ery. Apomorphine, stomach-tube, 
tincture of digitalis, 25 minims; aro¬ 
matic spirit of ammonia, 45 minims; 
brandy. Robinson (Boston Med. and 
Surg. Jour., p. 192, 1892). 


270 


ACONITE (SAJOUS). 


Reported by R. W. Greenleaf (Bos¬ 
ton Med. and Surg. Jour., July 15, 
1897). [The tincture of aconite re¬ 
ferred to is that of the old U. S. P.— 
Ed.] 

Case of a man, aged 26, who drank 
about three-fourths of an ounce of 
the tincture of aconite. He imme¬ 
diately discovered his mistake, and 
took about a tablespoonful of ground 
mustard in water, but could not 
vomit. The writer administered cider 
vinegar about fifteen minutes after 
drinking the aconite. He drank 
about a half-pint and another half¬ 
pint out of a quart jar. In less than 
five minutes he was greatly relieved, 
and his pulse was much better. The 
vinegar almost immediately relieved 
the burning and choking sensation in 
his throat. His saliva, which was 
thick and stringy (hanging down 
three or four feet, at the writer’s ar¬ 
rival, on his attempt to spit), did not 
change its character for at least half 
an hour. It gradually became nor¬ 
mal. All the symptoms gradually 
subsided. C. M. Swincle (Homeo. 
Recorder, Oct. 15, 1908). 
THERAPEUTICS.— Aconite is 
mainly used as a circulatory sedative. 
It lessens the blood-pressure by dimin¬ 
ishing the force and rapidity of the 
heart’s action, and is, therefore, indi¬ 
cated where a frequent and tense pulse 
is associated with excessive cardiac 
activity. It also tends to counteract 
spasm and relieve undue excitability 
of the nerve-centers, though its prop¬ 
erty of depressing the cutaneous 
sensory nerve-terminals is more 
marked, and is frequently availed of 
in neuralgic affections. 

In some patients, and under some 
conditions of acute infection, like 
that of acute bronchitis, the reaction 
of the system is almost violent. The 
temperature of the patient rises 
rapidly to 104° F. (40° C.) or higher, 
the heart beats with greatly increased 
vigor and frequency, there is a full 
pulse of high tension, a considerable 


rise in blood-pressure, and an accel¬ 
eration of respiratory activity. So 
sharp is the attack of the invading 
organism, and so vigorous the reac¬ 
tion of the system, that for the time 
being there seems actual danger of 
nature overstepping herself^and cre¬ 
ating mischief through excessive 
activity. It is in such cases that some 
external regulating influence seems 
advisable. In such reactions aconite 
is the only drug whose pharmaco¬ 
logical provings show a true indica¬ 
tion. A. D. Bush (N. Y. Med. Jour., 
Jan. 22, 1916). 

Aconite causing increased respira¬ 
tion, it is indicated where, with a 
high pulse, there is dryness of the 
skin. The evaporation of sweat from 
the surface and the heat radiation 
due to the increased peripheral circu¬ 
lation resulting from relaxation of 
the cutaneous capillaries also cause a 
reduction of temperature. Aconite 
also possesses diuretic properties. 
Hence it appears to be endowed with 
all the qualities requisite in the in¬ 
cipient stage of uncomplicated in¬ 
flammatory disorders, as an anodyne 
sedative. 

Aconite is the most efficacious 
vasodilator when given systematically 
in full doses. Aconite thus adminis¬ 
tered at once reduces blood-pressure, 
produces a full and compressible 
pulse, and greatly increases the per¬ 
centage of the elimination of urea in 
interstitial nephritis. Fie prefers it 
to all nitrites, as their vasodilating 
effects are too transient, the most 
prolonged of them, that of the ery- 
throl tetranitrate, lasting for less 
than an hour, which is by no means 
sufficient for such a permanent mor¬ 
bid condition of general arterial con¬ 
traction, with heightened blood- 
pressure, as is present in chronic in¬ 
terstitial nephritis. The most im¬ 
portant action in interstitial nephritis is 
to increase the elimination of urea. 
W. Hanna Thomson (Amer. Jour. 
Med. Sci., Jan,, 1915). 


ACONITE (SAJOUS). 


271 


In children aconite may be given 
whenever the spasmodic element is 
clearly marked: in fever preceding at¬ 
tacks of quinsy, pharyngitis, etc.; in 
asthma and the asthmatic crises of 
bronchial adenopathy; in pertussis 
and other spasmodic coughs; in 
laryngismus stridulus; in palpitations 
associated or not with hypertrophy of 
the heart, and in convulsions. 

The physiological effects enumerated 
afford sufficient ground for its value in 
the reduction of all the phenomena at¬ 
tending the fever: high temperature, 
dry skin, hard and frequent pulse, etc. 
The tincture is preferable here, as it is 
in all other disorders. The best effects 
are produced by means of small doses. 
One minim is first given, then another 
minim in one-half hour. After that, 
\y 2 minims are given every half-hour 
until the febrile symptoms are reduced 
or until physiological symptoms of the 
drug appear. Aconite should always 
be greatly diluted. 

Its antipyretic power being less than 
that of certain newer remedies (coal- 
tar antipyretics), however, the latter 
generally (though very much less than 
formerly) find more favor where a 
marked reduction of temperature is 
desired, unless the additional indica¬ 
tions for the use of aconite, such as an 
overactive heart, frequent pulse, or dry 
skin, be strongly marked. Its action in 
favoring perspiration may be enhanced 
by combination with other diaphoretics, 
such as the alkalies or pilocarpine. 

Aconite is used in the fever attend¬ 
ing the incipient stage of catarrhal 
disorders. It may be used as an anti¬ 
pyretic in continued fevers and in¬ 
fectious diseases,—variola, scarlatina, 
erysipelas, etc.,—but large doses are 
usually required, involving corre¬ 
spondingly great danger. It is better 


used in moderate doses for general 
sedative and diaphoretic effects in 
less severe infectious fevers, such as 
measles, mild scarlatina, rubella, and 
in the group of “ephemeral” fevers. 
According to Tison, aconitine re¬ 
duces the pain and shortens the 
duration of erysipelas; he used acon¬ 
itine nitrate in doses of % 4 o grain 
every two hours, not exceeding 10 
such doses daily. 

In the reflex fever which some¬ 
times follows the use of the catheter 
it has been found very efficient by 
several observers. 

In acute disorders of the nose, throat, 
and lungs the sedative effects exerted 
by aconite upon respiration through its 
influence upon the respiratory center 
are added to the properties previously 
enumerated. Hence its use in acute 
coryza, pharyngitis, tonsillitis, trach¬ 
eitis, bronchitis, pleurisy, and pneu¬ 
monia. Dujardin-Beaumetz uses aconi¬ 
tine when the lungs are congested, 
and especially in influenza. In all 
of these, 2 drops of the tincture 
every hour should be administered 
until the physiological effects—ting¬ 
ling and numbness of the lips and 
tongue—are experienced, when the 
remedy should be given less fre¬ 
quently. After the initial stage of the 
affections enumerated, aconite should 
be discontinued, especially in pneu¬ 
monia, in which affection its adminis¬ 
tration is positively harmful as soon as 
the asthenic stage begins. Aconite has 
been used in hemoptysis and epi- 
staxis tO’ lower the blood-pressure and 
favor cessation of the hemorrhage. In 
the chronic disorders of the respira¬ 
tory passages—including phthisis—it 
is more hurtful than therapeutically 
beneficial. 

In children aconite has proven useful 


272 


ACONITE (3AJOUS). 


in coryza, tonsillitis, spasmodic 
croup, asthma, whooping-cough, etc. 

Aconite has been employed in all 
forms of rheumatism, as well as in 
gout, to relieve pain and reduce con¬ 
gestion. It is especially indicated 
when the skin is dry. It is believed 
to have particular value in the acute 
rheumatic pains due to exposure. In 
chronic rheumatism it may be used 
in the form of a 2 per cent, ointment 
of aconitine. Hutchinson has found 
tincture of aconite beneficial in rheu¬ 
matic iritis. He gives 5 minims, three 
times a day, in conjunction with 
potassium iodide and the alkalies. 

Meningitis, pericarditis, and peri¬ 
tonitis are mentioned concurrently 
owing to the fact that their early 
manifestations are equally influenced 
by aconite. In peritonitis especially, 
its efiect as an anodyne tends to pre¬ 
vent vomiting: an important feature. 
In pericarditis it increases the 
chances of recovery by reducing the 
number of pulsations, thus prolong¬ 
ing the resting periods between 
beats. It should, however, be used 
with caution in these conditions, in 
view of its somewhat variable general 
depressant action. 

The sedative efifect of aconite upon 
the sensory nerves and nerve-endings 
has led to its frequent use, internally or 
locally, in neuralgia and neuritis. 
Certain authors consider it specially 
effective in neuralgia of the trifacial 
nerve. In neuralgia of the intermittent 
type, a combination of aconite with 
quinine will often be found serviceable. 
In the form of neuralgia characterized 
by exacerbations during damp weather 
aconite is sometimes effective in small 
doses frequently repeated. If the pain¬ 
ful spot does not cover much surface, 
application of the tincture over it with 


a camel’s hair pencil contributes mark¬ 
edly to hasten the relief. The drug 
may also be applied as a liniment or by 
inunction (see Modes of Administra¬ 
tion). The pain of neuritis resulting 
from exposure to cold is sometimes 
favorably influenced by aconite. In 
pain due to disturbances of the central 
nervous structures, however, the drug 
has not been found of great value. 

By lowering arterial tension and 
diminishing the number of heart-beats 
it may be of marked advantage in func¬ 
tional cardiac disorders, but when 
organic lesions are present it had better 
not be used. It is not infrequently 
employed in uncomplicated hyper¬ 
trophy, in nervous palpitation, and in 
the tobacco-heart, to antagonize ex¬ 
aggerated action, but its effects 
should be closely watched lest incip¬ 
ient degeneration be present. The 
dose generally used is from 2 to 5 
minims of the tincture three times 
daily, though some advise larger 
amounts. 

A 2 per cent, ointment of the alkaloid 
aconitine has sometimes been applied to 
relieve pain and itching in affections 
such as herpes zoster, eczema, pruri¬ 
tus, etc. 

As suggested by Dr. G. W. Rob¬ 
erts, a solution of aconite in water is 
very efficient in stubborn pruritus. 
One dram (4 Gm.) of the tincture in 
8 ounces (250 Gm.) of water or twice 
this strength may be used to “bathe” 
the Itching area, using a soft cloth or 
sponge. H. T. Webster (Elling- 
wood’s Therapeutist, Sept. 15, 1909). 

Dysmenorrhea due to congestion 
of the pelvic organs, metrorrhagia, 
and amenorrhea resulting from ex¬ 
posure to cold have all been mark¬ 
edly benefited by aconite. In the 
vomiting of pregnancy aconite in 
moderately large doses is often found 


ACROMEGALY (LAUNOIS AND CESBRON). 


273 


to give relief, owing to its sedative 
effect upon the nervous structures 
involved in the reflex act. 

Aconite has been used with benefit in 
acute gonorrhea, 1 minim of the tinc¬ 
ture being given every hour (Ringer). 
It is also advantageous as an anodyne 
in epididymitis. 

C. E. DE M. Sajous, 

AND 

L. T. DE M. Sajous, 

Philadelphia. 

ACROCYANOSIS. See Vascu¬ 
lar System, Disorders of, under 
Acroparesthesia. 

ACROMEGALY: PIERRE 
MARIE’S DISEASE.-D E FI - 
NITION. —Acromegaly is a general 
syndrome due, in almost every instance, 
to tumor of the hypophysis, character¬ 
ized by progressive enlargement of the 
osseous and other supporting tissues, 
and primarily and chiefly noticeable in 
the extremities. It was first described 
by Pierre Marie in 1886. 

SYMPTOMATOLOGY.— The most 
prominent characteristic of the ‘'acro¬ 
megalic dystrophy’ is, as stated 
above, a progressive enlargement of 
the extremities. Although the de¬ 
formities are particularly noticeable 
in naturally prominent portions of the 
body, they also involve other regions, 
such as the skull, face, spinal column, 
and thorax, and are very marked in 
these regions as well. 

An outline of the general appearance 
of the acromegalic patient—that odd, 
ungainly, and unharmonious creature— 
may prove profitable before the disease 
is studied in detail. His enormous, 
clumsy hands seem all the more massive 
from the fact that the forearms have 
retained their normal proportions. They 
present a “stuffed” appearance, and ter¬ 

1 - 


minate in thickened, sausage-like fin¬ 
gers. His broadened feet are mere 
paws, with toes of exaggerated size. 
The face is long, the forehead narrow 
and retreating, and the supraorbital 
arches enlarged; the eyes often project 
forward from between the thickened 
eyelids; the nose stretches out laterally 
its fleshy alae; the lips are enormous, 
especially the lower, which is everted; 
the lower jaw is strongly prognathic; 
the tongue, unusually large, frequently 
protrudes from the mouth. This repul¬ 
sive and beast-like head, bounded later¬ 
ally by ears of monumental size, is bent 
forward and set deeply between the 
shoulders. Though of average stature, 
or above the average, the subject ap¬ 
pears partially collapsed; the curvature 
of his back and the thoracic deformity 
contribute to his humiliation, which is 
further accentuated by his torpid and 
melancholy demeanor. From a distance 
his appearance is so striking that the 
diagnosis can be made without detailed 
inspection. When the deformities are 
fully developed, all acromegalics bear a 
strong resemblance, and the adage, “a& 
lino disce omnes” is here truly appli¬ 
cable. 

The increased bulk of the hands is 
often the first change to attract atten¬ 
tion. The hands become broader and 
thicker without augmenting in length. 
The hypertrophy involves all the com¬ 
ponent tissues of the part,—bones, mus¬ 
cles, subcutaneous cellular and fatty tis¬ 
sues, and skin. The latter is hard, firm, 
free of edema, and somewhat darkened 
in color. The interphalangeal folds, ab¬ 
normally developed, extend between 
what may be called wads of flesh,—the 
“main capitonnee.” The thenar and 
hypothenar eminences are greatly over¬ 
developed, and the linear grooves of the 
palm are transformed into deep gutters. 


274 


ACROMEGALY (LAUNOIS AND CESBRON). 


The fingers are somewhat flattened 
from before backward, and are of equal 
thickness distally and proximally. The 
thumb measures up to 12 cm. in circum¬ 
ference (Lombroso), the index finger 
9 cm., and the medius 10 cm. The nails 
remain relatively small. They become 
flattened, turn up at the edges, and show 
longitudinal striations. In exceptional 
cases a club-shaped deformity of the 
fingers, or the presence of nodosities at 
the interphalangeal joints, has been 
noted. Notwithstanding the unusual 
proportions of the acromegalic hand, 
its functions are generally preserved, 
complete flexion becoming impossible, 
however, in cases where the palm is 
markedly thickened. De Souza-Leite 
observed the “dead finger” phenomenon 
twice in 38 cases. 

In contradistinction to this massive 
voluminous, or ''transverse"' type, Pierre 
Marie has described a second variety of 
deformity involving the hands. In this 
type they again undergo a general in¬ 
crease in size, but there is added a 
growth in length which is about propor¬ 
tionate to that in breadth. Being longer, 
the hands thus appear lighter and less 
clumsy than in the massive form, where 
the overgrowth is almost solely trans¬ 
verse. This "longitudinal type is seen 
more particularly in subjects in whom 
the dystrophy developed at a relatively 
early period. We have met with it in 
our infantile acromegalic giants. 

These deformities of the hand gen- 
eially stop at the wrist, at least during 
the earlier stages. Later on, the hyper¬ 
trophy becomes generalized, the other 
segments of the upper extremity—fore¬ 
arm and arm—being also involved. 

The feet, like the hands, become 
broader and thicker, without greatly in¬ 
creasing in length. They present the 
same fleshy pads, surrounded by deep 


grooves. The skin is darker, but is of 
similar consistency. The toes, especially 
the great toe, reach altogether remark¬ 
able dimensions, and the nails are af¬ 
fected much as in the upper extremity. 
According to Verstraeten, the heels are 
always enlarged. The hypertrophic en¬ 
largement generally terminates above 
the leg. The knee, if early involved, 
is enlarged but slightly, and the foot al¬ 
ways contrasts, by its exaggerated bulk, 
with the rest of the limb. 

The acromegalic facies, besides the 
characteristics already noted, includes a 
striking prominence of the supraorbital 
ridges, which project to an extent cor¬ 
responding to the degree of enlarge¬ 
ment of the frontal sinuses. The eyes 
are lacking in expression, and appear 
relatively small in comparison with the 
capaciousness of the orbits, notwith¬ 
standing the exophthalmos occasionally 
observed. The eyelids are thickened 
either in toto or merely in the region of 
the tarsal cartilages. The temporal fos¬ 
sae becoming deeper, the malar promi¬ 
nences appear to stand out more 
strongly. The nose undergoes general 
enlargement, and is distinctly broadened 
and flattened. Its alae are heaviest 
inferiorly, and the septum is doubled 
in thickness. The lips are enlarged, 
particularly the lower, which is also 
everted. The mouth, often half open, 
reveals a tongue of enormous bulk. The 
movements of the tongue are poorly ex¬ 
ecuted; the organ interferes with mas¬ 
tication and articulation, is frequently 
injured by the teeth, and sometimes 
shows fissures at its borders. The roof 
of the mouth, soft palate, faucial pillars, 
tonsils, uvula, and larynx all exhibit 
hypertrophic changes. In female sub¬ 
jects, the thyroid cartilage, in its hyper¬ 
trophied state, recalls the “Adam’s 
apple” normally seen in the male. 



Acromegaly. 


(P. E. Launois.) 









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Acromegalic Profile. (P. E. Launois.) 







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W.4I1 



ACROMEGALY (LAUNOIS AND CESBRON). 


275 


Laryngoscopic examination reveals both 
elongation and thickening of the vocal 
cords. These various changes in the 
organ of phonation impart to the voice 
a distinctive deep and at the same time 
metallic quality. 

While the alterations in the superior 
maxilla are apparently not pronounced, 
those involving the lower jaw are some¬ 
times extremely marked. The chin, 
large and massive, projects downward 
and forward, forming an obtuse angle 
with the rami of the jaw-bone. The 
lower teeth, which Henrot has found 
to be hypertrophied, are spread apart, 
and, owing to their forward projection, 
can no longer be opposed to the upper 
dental arch. 

The profile is most characteristic, and 
bears witness to the extraordinary de¬ 
gree of prognathism sometimes at¬ 
tained. The description of the acro¬ 
megalic facies would not be complete 
without a mention of the broadened 
ears, with their lobules of undue size. 

The facial skin is dry, brownish yel¬ 
low in color, and often presents warty 
excrescences. The hairs covering the 
head are individually thickened, and, 
taken collectively, apparently exhibit a 
heavier growth. The eyelashes and 
other short hairy appendages are also 
coarse and stiff. 

The bones of the cranium proper 
show modifications similar to those in 
the facial bones. These changes will be 
described later, when the results ob¬ 
tained by radiogrp/phic examination are 
discussed. 

In the spinal region, the vertebrae, 
taken as a whole, show increased vol¬ 
ume. As a result, changes in the spinal 
curves are brought about, consisting, 
more specifically, of a cervicodorsal 
kyphosis, with or without lumbar lor¬ 
dosis and scoliosis. 


The thorax becomes more capacious 
and undergoes alterations in shape. It 
becomes prominent anteriorly. Though 
its anteroposterior diameter is increased, 
it is flattened laterally. The broadened 
sternum tends especially to spread put 
above, and develops transverse ridges. 
The clavicles become thickened and 
their curves exaggerated. The ribs 
come mutually into contact, or even 
overlap, and the costal cartilages become 
ossified. The lower costal arches slant 



Acromeg-aHc macrofirlossia. {P. IC. Launoia.) 


downward, sometimes so markedly as 
to reach the crest of the ilium when the 
subject is in the sitting posture. The 
scapulae are thickened, and their acro¬ 
mial and coracoid processes stand out 
in bold relief beneath the skin. 

These deformities interfere in some 
degree with the thoracic excursions, 
sufficiently so, indeed, to bring about, 
among acromegalic subjects, a modifi¬ 
cation in the type of breathing, which 
becomes permanently abdominal. When 
they are all present in the same patient 
and are very pronounced, a double hump 
in the back may be pronounced, recall¬ 
ing the classic conformation of the Ital- 


276 


ACROMEGALY (LAUNOIS AND CESBRON). 


ian Punchinello, whom Pierre Marie 
considers the ances.tor of acromegalics. 

The dystrophy makes its first appear¬ 
ance at the distal ends of the extremi¬ 
ties. The patient’s attention is often 
attracted to the condition by the con¬ 
stantly increasing tightness of his gloves 
and footwear. In some instances the 



Cervicodorsal kyphosis in a case ot 
acromegaly. {Pierre Marie.) 

family or neighbors notice changes tak¬ 
ing place in the facies. Once estab¬ 
lished, the afifection progresses steadily 
and more or less rapidly. If the patient 
be a woman, she becomes aware of the 
progressively larger size of thimble she 
requires in her sewing. The male pa¬ 
tient, on the other hand, is struck by the 
increasing diameter of his headgear. 

From the distal portions, the changes 
proceed to the proximal segments of 


the limbs, which, by their hypertrophy, 
may assume a markedly athletic aspect. 
Muscular power, however, almost al¬ 
ways shows a gradual decrease; not¬ 
withstanding their bulk, the contractile 
power of the muscles does not bear the 
normal ratio to their size. A certain 
degree of muscular atrophy has occa¬ 
sionally been noted; in a case studied 
by Duchesneau (These de Lyon, 1901) 
it was so pronounced as to lead this 
observer to suggest the advisability of 
dififerentiating an amyotrophic form of 
the disease. The muscles show no note¬ 
worthy electrical disturbances; their ex¬ 
citability is diminished according toErb, 
exaggerated according to Verstraeten. 
The patellar reflexes are either normal, 
diminished, or lost; they are never ex¬ 
aggerated. 

In certain joints, such as the knee, 
wrist, and elbow, there have been ob¬ 
served enlargement and painful crack¬ 
ling, recalling somewhat the phenom¬ 
ena noted in mild arthropathies. 

The circulatory system presents an 
interesting group of alterations. Vari¬ 
cose veins are said to be frequent, and 
the heart is often hypertrophied. 

[In 1895 Huchard pointed out the existence 
of more or less marked cardiovascular dis¬ 
turbances. His pupil, J. B. Fournier (These 
de Paris, 1896), having collected 25 cases, 
including 12 with autopsy, was led to distin¬ 
guish two varieties of cardiac hypertrophy, 
the one, slight and without degeneration of 
the muscular fibers; the other, accompanied 
by sclerosis and atrophy of the contractile 
elements. Launois and Cesbron.] 

Symptomatically these changes in the 
cardiac tissues find their expression in 
palpitations, arrhythmia, and dyspnea, 
and may result finally in asystole. Syn¬ 
copal attacks are said to be not uncom¬ 
mon. Spinal deformities, when marked, 
may result in dilatation of the right 
heart. 




Acromegaly in the Aged—Strabismus. (P. E. Launois.) 








ACROMEGALY (LAUNOIS AND CESBRON). 


277 


Hypertrophy of the lymphatic vessels 
and glands has also been reported. 

Sensation^ on the whole, does not ap¬ 
pear to be affected. Unusual sensitive¬ 
ness to cold is, however, present to a 
certain extent. 

The various deformities that we 
have described arise and progress, as a 
rule, without giving rise to pain. In 
some instances, however, their develop¬ 
ment is accompanied by more or less 
severe painful crises, sometimes re¬ 
ferred to the viscera, at other times to 
the limbs. While sometimes taking the 
form of a simple myalgia, they may also 


striking component of the syndrome re¬ 
sulting from tumors of the hypophysis, 
and it is because it has drawn our atten¬ 
tion to the hypophysis that the syn¬ 
drome due to hypophyseal growths has 
brought forth such a wealth of litera¬ 
ture as to make it at present, perhaps, 
the most abundantly discussed of the 
syndrome caused by brain tumors. 

We consider acromegaly to be an in¬ 
tegral part of the hypophyseal syn¬ 
drome, and, indeed, with the exception 
of certain rare cases acromegaly unac¬ 
companied by tumor of the hypophysis 
does not occur, while, on the other hand. 



Series of thimbles used by an acromeg^alic woman. 


develop into severe neuralgia, and are 
then aggravated by exposure to cold 
and dampness. This painful form of 
the disease (Sainton and State, Revue 
Neurologique, p. 30, 1900, and These de 
Paris, 1900) may also assume the rheu¬ 
matoid type when it becomes localized 
in a certain group of joints. 

THE HYPOPHYSEAL SYN¬ 
DROME. —Until recent years the nat¬ 
ural history of acromegaly would have 
been covered by a description such as 
the above. The advances since made, 
however, both along clinical lines and 
in the pathology of the disease, owing 
to the use of the X-rays and to im¬ 
proved histological technique, have 
brought about modifications of our ear¬ 
lier ideas. Previously considered an in¬ 
dividual affection, to which the name 
“Pierre Marie’s disease” had properly 
been applied, acromegaly was found to 
be, in reality, only the most peculiar and 


the close relationship of the disease to 
such tumors seems established. 

The affection generally makes its ap¬ 
pearance long before the other compo¬ 
nents of the syndrome, which may be 
interpreted as disturbances due to com¬ 
pression ; on the other hand, in no 
case has a tumor in the region of the 
hypophysis been known to produce 
acromegaly unless developed from the 
hypophysis itself. Acromegaly almost 
certainly implies the existence of a 
tumor of the hypophysis. The converse 
is, however, not always true, every 
tumor of the hypophysis not necessarily 
resulting in acromegaly. 

Clinically, tumors of the pituitary, the 
frequency, nature and characteristics of 
which we shall mention later, betray 
their presence by an aggregate of signs 
and symptoms included under the term 
“hypophyseal syndrome.” We may 
divide these signs and symptoms, fol- 


2/8 ACROMEGALY (LAUNOIS AND CESBRON). 


lowing the example of the obstetricians, 
into the three following groups: 1, 
Probable signs and symptoms of pitui¬ 
tary tumor. 2. Quasi-positive signs and 
symptoms. 3. Positive signs. 

The first are those of brain-tumor 
zvith special localization. Through its 
increased size, the pituitary expands the 
bony fossa in which it is lodged and 
soon begins to project upward above it, 
indenting the lower surface of the cere¬ 
brum. It exerts more or less pressure 
on the neighboring structures, and 
causes a certain degree of increased in¬ 
tracranial tension. 

The earliest symptom of it is head¬ 
ache. The pain tends to become local¬ 
ized anteriorly; these patients often 
complain of a sensation of heaviness 
which impels them half unconsciously 
to rub their forehead and eyes, as 
one does ordinarily upon awakening’^ 
(Payer). In certain cases, the pain is 
more definitely localized. 

In some cases the progress of the 
disease is so nearly painless that the 
discovery post mortem of an almost 
complete flattening of the basal convolu¬ 
tions, whereas in life only trifling mi¬ 
graine had been recorded, becomes a 
matter of surprise. 

-Along with the headache should be 
mentioned vertigo and vomiting of cere¬ 
bral type, which are among the usual 
signs of intracranial tumors. 

With the symptoms are generally as¬ 
sociated melancholic tendencies, loss of 
memory, and mental and physical tor¬ 
por. Apathy sometimes reaches such 
a degree that the power of executing 
voluntary acts seems practically lost. It 
was very pronounced in the peculiar 
case described by Payer: ‘‘During the 
morning visit, when asked to rise, he 
promised to put on his clothes at once, 
yet at 5 o’clock in the afternoon, not¬ 


withstanding reix:ated requests by the 
nurse, he was still in bed. When obliged 
to relinquish his room in the daytime, 
he would leave only to sit motionless 
in an armchair or to slumber in an ad¬ 
joining room. The positions he assumed 
were those of an exhausted, flaccid, and 
semiunconscious individual.” Convul¬ 
sive movements may also be observed, 
sometimes confined to the face, in other 
instances involving the limbs. 

In establishing a diagnosis of brain 
tumor in general, and of tumor of the 
hypophysis in particular, no signs should 
be overlooked, and we must, therefore, 
not forget to mention as possible symp¬ 
toms cramps, contractures. These may 
be related to the coexisting hydro¬ 
cephalic condition, since they disap¬ 
peared, in a patient of von Hippel, 
upon the removal of cerebrospinal fluid 
through a nasal opening. The tremor 
observed by Stroebe and the ataxia of 
the lower extremities reported by Hen- 
neberg are probably to be referred to 
some similar cause. 

Peculiar anomalies of taste occasion¬ 
ally appear, consisting of strongly ex¬ 
pressed desires on the part of some pa¬ 
tients to eat most unusual articles of 
food. 

Tinnitus aurium, peculiar in that it 
appears only on the side upon which 
the patient is lying, has been noted. 

Pressure may be exerted upon the 
sinuses adjoining the hypophysis and 
cause disturbances in the venous circu¬ 
lation, as shown by facial edema. 

The writer, on the basis of 4 cases 
observed by him, emphasizes the im¬ 
portance of acromegaly of the larynx, 
the laryngeal changes being sufficient 
to produce stenosis demanding tra¬ 
cheotomy. In one instance the lat¬ 
ter operation alone saved the pa¬ 
tients life; in another case marked 
changes in the larynx ended in sud- 


■ACROMEGALY (LAUNOIS AND CESBRON). 


279 


den death apparently from asphyxia. 
In 3 of the 4 cases the laryngeal 
image was not symmetrical although 
the laryngeal enlargement seemed 
so on palpation. Asthma-like attacks 
or dyspnea or a harsh and weak, or 
masculine voice in the female, may 
form part of the syndrome. Chevalier 


for weeks at a time between 34° and 
36° C. ( 931 / 5 ° and 96 / 5 ° F.) without 
the supervention of any sign of collapse. 

Torpor and asthenia are, as we have 
stated, among the ordinary manifesta¬ 
tions of acromegaly. Exaggeration of 
these symptoms, in the hypophyseal 


Young: acromegralic woman. In lower rig:ht-hand corner, same patient at the agre of 20 
soon after onset of the affection. (P. E. Launois.) 



Jackson (Jour. Amer. Med. Assoc., 
Nov. 30, 1918). 

Among the circulatory changes that 
may be produced is to be added to those 
already mentioned the somewhat para¬ 
doxical acceleration of the pulse, re¬ 
ported by Engel. 

A no less singular manifestation is 
lowering of the internal temperature, 
which, in a patient of Bartels, remained 


syndrome, may give the appearance of 
sleeping spells/^ 

True psychoses occur with extraordi¬ 
nary frequency in cases of tumor of the 
hypophysis. Schuster, who has made 
a special study of the psychic dis¬ 
turbances observed in brain tumors, be¬ 
lieves that they are met with in almost 
one-half of the cases of tumor of the 
hypophysis. This proportion will not 








280 


ACROMEGALY (LAUNOIS AND CESBRON). 


seem surprising if we recall the fact that 
the first pathological observations on 
hypophyseal tumors were made in asy¬ 
lums for the insane. History affords 
a conspicuous example of this in the 
person of Cromweirs giant porter, a 
maniac with prophesying tendencies, 
whom it was found necessary to confine. 

In the literature on the pathology of 
tumors of the hypophysis we often come 
across the words “amaurotic insanity'* 
as a heading in clinical records. This 
accompaniment of these tumors, long 
overlooked, was but recently given due 
emphasis by Frohlich, and particularly 
by Cestan and Halberstadt. The vari¬ 
ous forms of delirium, delusions of per¬ 
secution, mystery, and the manic-de¬ 
pressive psychosis may be encountered. 
An interesting fact has been reported 
by Moutier (“Acromegalie: crises 
epilepti formes avec equivalents psy- 
chiques,” Revue neurologique, Nov. 8, 
1906) in the occurrence in an amblyopic 
acromegalic of rather frequent epilepti¬ 
form seizures, due evidently to the 
cerebral tumor present. In the inter¬ 
vals between seizures he was subject 
to “absent periods,” during which he 
would sometimes remain perfectly still, 
or else perform a large number of 
unreasoning acts of which he lost all 
memory after the attack had subsided. 

Polyuria and glycosuria are often en¬ 
countered in cases of tumor of the hy¬ 
pophysis. That the presence of sugar 
was not more frequently reported by 
the earlier observers is due to the fact 
that they were not in the habit of ex¬ 
amining the urine in their cases system¬ 
atically. Loeb (Deutsch. Archiv f. 
klin. Med., p, 449, xxxiv, 1884; Cen- 
tralbl. f. innere Med., 1898) was the 
first to point out the frequency of 
melituria in disease of the hypophysis. 
He explained it as being due to the 


pressure which may indirectly be ex¬ 
erted by tumors of this gland on the 
floor of the fourth ventricle and neigh¬ 
boring structures. 

Glycosuria of hypophyseal causation, 
though more or less constantly present, 
may show wide variations in intensity. 
In a patient of Finzi (Boll, della Soc. 
Med. di Bologna, No. 4, 1894), for in¬ 
stance, the sugar, after having been 
present in large amounts, gradually dis¬ 
appeared completely from the urine. 
In February, 1888, Striimpell (Deutsch. 
Archiv f. Nervenheilkunde, 1897) noted 
a marked glycosuria in one of his cases. 
In May of the same year the sugar had 
disappeared. It reappeared in October, 
then did not return, even after the in¬ 
gestion of a large quantity of carbohy¬ 
drates. 

Of the 176 cases of acromegaly re¬ 
ported so far, 35.5 per cent, included 
glycosuria as a symptom. Experi¬ 
ments were made, injecting hypo- 
• physeal extract obtained from men 
and horses into dogs and rabbits. In 
the rabbits a glycosuria varying from 
a slight trace to 4.2 per cent, always 
occurred. Borchardt (Zeit. f. klin. 
Med., Bd. Ixvi, S. 332, 1908). 

In a case reported by the writer the 
glycosuria was not due to a secretion 
but to nerve irritation of the floor of 
the third ventricle by an enlarged 
sella. Lereboullet (Progres Med., 
Mar. 6, 1920). 

In 215 reported cases studied by 
the writer, 91 had thyroid lesions 
and glycosuria was present in 35 per 
cent. The pituitary disturbance 
seemed to precede that of the thy¬ 
roid. J. M. Anders (Trans. Med. Soc. 
State of N. Y.; Jour. Amer. Med. 
Assoc., June 4, 1921). 

Dallemagne, Pineles, and von Hanse- 
mann have found lesions of the pan¬ 
creas at the autopsy. The first of these 
observers, in addition, noted the pres¬ 
ence of small gliomatous formations in 
the region of the fourth ventricle. 


ACROMEGALY (LAUNOIS A'ND CESBRON). 


281 


According to Lorand the glycosuria 
results from disturbance in the internal 
secretion of the hypophysis, and is a 
component of one of the polyglandular 
syndromes, to learn the precise nature 
of which investigations are now being 
conducted. 

Loeb believes it due to pressure ex¬ 
erted on the structures at the base of the 
brain, and, since, of all cerebral tumors, 
those developing from, or in the neigh¬ 
borhood of, the hypophysis are the most 
likely to cause glycosuria, he is of the 
opinion that a center regulating the 
metabolism of sugar exists in this re¬ 
gion. The center discovered by Claude 
Bernard in the floor of the fourth ven¬ 
tricle would thus not be the only one of 
this kind; Schiff, indeed, appears to 
have found other such centers in the 
optic thalami, crura cerebri, and pons. 
Eckhardt produced glycosuria in rab¬ 
bits by injuring the vermis of the cere¬ 
bellum, and, returning to clinical and 
pathological records, we may recall that 
Lepine observed diabetes in a case of 
softening of the central gray nuclei, and 
Loeb and Naunyn in cases of cerebral 
hemorrhage. 

According to the views of Sajous 
(“The Internal Secretions and the Prin¬ 
ciples of Medicine,” vol. i, 1903; vol. ii, 
1907; Gazette des Hopitaux, Mar. 10, 
No. 29, 1907), who holds that a nervous 
center exists in the hypophysis, and that 
the several ductless glands are con¬ 
nected by a nervous pathway, a ready 
explanation is afforded. Diabetes of 
hypophyseal origin is the result of an 
irritation, a disturbance produced in the 
nervous center which the gland con¬ 
tains, in the same way that the nerve- 
path, in its bulbar course, is influenced 
by puncture of the fourth ventricle. 

Whether we adopt the view of Loeb, 
involving pressure changes, or that of 


Sajous, relative to nervous irritation, 
however, the presence of an interme¬ 
diary is further required for the produc¬ 
tion of glycosuria. According to some, 
this intermediary factor is the pancreas; 
in the opinion of Gilbert and his follow¬ 
ers, it is the liver which, under these 
conditions, becomes functionally over- 
active; according to Sajous, it is the 
adrenals, to which he traced nerves 
from the pituitary, the adrenal secre¬ 
tion augmenting through increased oxi¬ 
dation the production of amylopsin, 
which, in turn, increases abnormally 
the conversion of the hepatic glycogen 
into sugar. 

Rath, Oppenheim, Konigshoffer, and 
Weil have reported polydipsia together 
with polyuria in the entire absence of 
glycosuria. Bouchard has noted pep¬ 
tonuria and Duchesneau phosphaturia. 

Among the other disturbances of se¬ 
cretion, frequent and copious sweating 
should also be mentioned. 

The anatomical and functional 
changes taking place in the reproductive 
organs in acromegalic cases were early 
recognized. The penis, which, as Erb 
correctly remarks, is also an 
sometimes, though not regularly, attains 
a greater size than normal. In the fe¬ 
male, the clitoris may undergo corre¬ 
sponding hypertrophy, and the folds of 
skin forming its prepuce may become 
thickened. 

This enlargement of the genital or¬ 
gans should by no means be taken to 
imply increased functional activity. In¬ 
deed, male patients usually experience 
a diminution of desire and potency, 
which may progress to complete loss of 
the function. In the female, the most 
important result is suppression of the 
menses, which occurs so early in the dis¬ 
ease that in many cases it may be con¬ 
sidered the initial event. 


282 


ACROMEGALY (LAUNOIS AND CESBRON). 


The primary increase in size in the 
genital organs soon gives way to a true 
atrophy. In certain cases of hypophys¬ 
eal tumor which had not been accom¬ 
panied by acromegaly, the penis was ob¬ 
served to have dwindled to the size of 
the little finger, the testicles to have 
become small and soft, and the pubic 
hair diminished in amount. 

Pechkranz and Babinski were the first 
to report these changes. Roubinowitch 
published the interesting history of a 
patient, previously studied by Pierre 
Marie, who developed acromegaly after 
childbirth, and showed progressive atro¬ 
phy of the organs of generation. 

On the basis of published facts we 
may at present conclude that sexual 
atrophy can form part of the hypophys¬ 
eal syndrome, but that it is not inva¬ 
riably a consequence of tumors of the 
hypophysis. Coming on in youth, these 
tumors may cause arrest of development 
of the genital organs; appearing later, 
they may cause retrogressive changes in 
them. The problem has not yet been 
solved, since it will be necessary to de¬ 
termine more precisely in what measure 
the hypophysis is capable of producing 
genital atrophy. The experiments of 
Vassale, of Caselli, and of Sacchi seem 
to have demonstrated that removal of 
the gland in young animals, is without 
effect on their sexual development, but 
these animals have never survived any 
length of time. Moreover, a certain 
number of cases have been known, in¬ 
cluding those of Schmidt-Rimplex, of 
Gotzl and Erdheim, of Babinski (Revue 
Neurologique, vol. viii, p. 531, 1900), 
of Pechkranz, and of Bartels, in which 
the tumor causing genital atrophy did 
not involve the hypophysis. 

In our description of the acromegalic 
dystrophy we stated that the hypertro¬ 
phic changes witnessed were due to an 


abnormal development in the various 
connective tissues. This overgrowth 
may, however, be limited to certain 
parts of these tissues, and in particular 
to the panniculus adiposus. In 1901, 
Frohlich (Wiener klin. Rundschau, 
1901) drew attention to a special va¬ 
riety of adipose overgrowth occurring 
in cases of tumor of the hypophysis, and 
attaining considerable proportions. Erd¬ 
heim (Ziegler’s Beitrage, Bd. 33, 1903) 
confirmed the association of these two 
conditions, and a number of cases have 
recently been reported. The accumula¬ 
tion of fat under these circumstances is 
steady and more or less rapid. It may 
reach an enormous extent. 

With the adipose accumulations are 
often associated signs of increased in¬ 
tracranial tension, and at times, as we 
have remarked, mental disturbances. 

We are not as yet in a position to ex¬ 
plain the special involvement of the re¬ 
serve tissues in this affection, but will 
have to limit ourselves to recalling the 
following interesting observation re¬ 
ported by Madelung (Langenbeck’s Ar- 
chiv, Ixxiii, p. 1066) : A girl 6 years of 
age, having been shot in the head, began 
to put on fat six months later. Her 
weight doubled in the space of three 
years and reached 42 kg. (92 pounds). 
Examination with the X-rays revealed 
the bullet in the region of the infun¬ 
dibulum. 

Myxedema may form part of the hy¬ 
pophyseal syndrome. From the early 
observation of Norman Dalton (Lan¬ 
cet, No. 6, 1897) to that of Sainton and 
Rathery (Bull, de la Soc. Med. des 
Hop., May 8, 1908), a large number of 
cases have been reported which support 
the view that this combination may 
occur. 

The simultaneous presence of simple 
goiter and of Basedout/s disease has 



Lipomatous Type of Frohlich’s Syndrome. (P, E. Laimois.) 






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ACROMEGALY (LAUNOIS AND CESBRON). 


283 


likewise been reported. Although the 
association of these disorders is a point 
in favor of the existence of a poly¬ 
glandular syndrome, it would be rash at 
this time to attempt to define the latter 
precisely. 

The polyglandular syndrome was 
clearly marked in a case observed by 
the writer. The right lobe of the thy¬ 
roid showed a distinct enlargement 
of the colloid type; Addison’s was 
shown by a brownish discoloration of 
the face and arms and asthenia. 
Bendell (Albany Med. Annals, Sept., 

1915) . 

The writer observed a case of 
typical acromegaly in which an ex¬ 
treme degree of exophthalmos ex¬ 
isted along with the von Graefe, Dal- 
rymple, Stellwag and Gifford’s signs 
of Graves’s disease. Weidler (Bos¬ 
ton Med. and Surg. Jour., Apr. 6, 

1916) . 

Ophthalmic Disorders .—The quasi- 
positive signs of the presence of a tumor 
of the hypophysis are found in a study 
of the ocular disorders, which result 
from the close anatomical relationship 
of the pituitary gland to the optic path¬ 
ways. The visual disturbances long ago 
attracted and retained the attention of 
investigators. Among the earliest ob¬ 
servations should be remembered those 
of Vieussens (1705), and of Rullier 
(1823). Ocular disturbances are also 
mentioned in the papers of Rayer and 
of Friedreich. Bernhardt has summar¬ 
ized them as follows: “Slow, progress¬ 
ive amblyopia, terminating in absolute 
blindness. Since the latter does not re¬ 
sult from increased intracranial tension, 
but is generally due to pressure on the 
optic tracts, chiasm, and optic nerves, 
papillary edema is not generally present, 
primary atrophy taking place in most 
instances.^' . 

As for the events related more par¬ 
ticularly to acromegaly, Pierre Marie at 
first recorded merely optic neuritis in 


mild cases, absolute blindness in ad¬ 
vanced cases. Pinel-Maisonneuve in 
France, Schiiltze (Berl. klin. Wochen- 
schr., No. 38, 1889) in Germany, and, 
later, Boltz (Deutsche med. Wochen- 
schr., page 685, 1892), and Packard 
(Amer. Jour, of the Med. Sciences, p. 
660, 1892), sought to emphasize the 
diagnostic value of bitemporal hemian¬ 
opsia, i.e., loss of vision in the lateral 



Acromegaly with tumor of pituitary and 
goiter. iP. E. Launois.) 


halves of the two visual fields, with 
preservation of central vision. Since 
these earlier investigationSj numerous 
observations have been collected; the 
present tendency, based on these, is even 
to establish a distinction between tumors 
arising in the hypophysis itself and 
those developing simply in the hypo¬ 
physeal neighborhood. The former are 
not, in general, accompanied by pro¬ 
nounced disturbances of vision until a 
rather advanced stage. The morbid 
change in the optic nerve, however, al¬ 
most always progresses, and leads finally 




284 


ACROMEGALY (LAUNOiS AND CESBRON). 


to complete amaurosis of one or both 
eyes. 

The first sign afforded on systematic 
examination of the eyes is a diminution 
of visual acuity. But slightly marked 
at first, this generally undergoes grad¬ 
ual increase, absolute blindness being 
reached, in most instances, only after a 
period of ten or twelve years. Ordi¬ 
narily, one eye is more seriously affected 
than its fellow, and shows amaurosis at 
an earlier period. 

The condition sometimes runs a rapid 
course; it may disappear for a short 
time, then return and become definitely 
established. According to Oppenheim 
(Berliner klin. Wochenschr., No. 36, 
1887, and No. 29, 1888), the histolog¬ 
ical structure of tumors of the hypophy¬ 
sis, which are frequently very vascular, 
bears a casual relation to this “oscillat¬ 
ing vision.” From the rupture of ves¬ 
sels with their walls in an embryonal, 
formative state, followed by more or 
less extensive hemorrhage, sudden 
blindness might result. Eisenlohr (Vir¬ 
chow’s Archiv, Ixviii, p. 461) reports the 
case of a man who, without having pre¬ 
viously exhibited any pronounced dis¬ 
turbance, was suddenly seized with 
headache, vomiting, somnolence, and 
convulsive movements of the upper ex¬ 
tremities. At the same time the pupils 
were dilated and fixed, and double am¬ 
aurosis was present. The autopsy dis¬ 
closed in the sella turcica a rounded tu¬ 
mor of the size of a cherry, the existence 
of which had not been suspected during 
life, and which had been the seat of an 
extensive hemorrhage. In like manner 
Bayley (Philadelphia Med. Jour., April, 
1898) witnessed absolute blindness with 
partial oculomotor paralysis in a man 
of 50, who afterward showed a hemor¬ 
rhagic focus in the hypophysis. With 
these observations may be grouped those 


of Bassoe (Jour, of Nervous and Men¬ 
tal Diseases, Sept, and Oct., 1903) and 
Yamaguchi. In the case of a young girl 
who suffered complete loss of vision in 
three weeks, Woolcombe (Brit. Med. 
Jour., June, 1896) discovered the pres¬ 
ence of an exceedingly vascular psam¬ 
moma. 

Of still greater interest and impor¬ 
tance are the alterations in the fields of 
vision which accompany tumors of the 
hypophysis, and occur with particularly 
remarkable frequency in acromegaly. 
From the standpoint of diagnosis they 
are of primary importance. 

In 22 cases with autopsy in which 
changes in the visual fields had been re¬ 
corded, the percentage of each form of 
hemianopsia was as follows: Bitem¬ 
poral hemianopsia, 23 per cent.; unilat¬ 
eral temporal hemianopsia, 23 per cent.; 
homonymous hemianopsia, 9 per cent. 
Concentric reduction of the visual fields 
was recorded in 22 per cent, of the 
cases; an irregular contraction in 4 per 
cent.; in 9 per cent., but one quadrant 
was preserved; in 13 per cent, there was 
a central scotoma. 

Study of the eye symptoms in dis¬ 
ease of the pituitary body and acro¬ 
megaly based on 328 autopsies. Tem¬ 
poral hemianopsia is the most constant 
symptom; typical choked disk and.slight 
papillitis each occurred in about 5 per 
cent, of the cases, simple atrophic pal¬ 
lor of the disks in 20 per cent., and cen¬ 
tral scotoma only in occasional cases. 
Paralysis of ocular muscles, generally 
affecting the oculomotor nerve, occurred 
in 10 per cent, of cases, and nystagmus 
in 6 per cent. W. Uhthoff (Lancet, 
Sept. 4, 1909). 

These results will, at first sight, ap¬ 
pear somewhat inconstant. This vari¬ 
ability in the alterations of the visual 
fields is, however, to be accounted for 
by the fact that the visual tests were 
made at different stages of the affection 


ACROMEGALY (LAUNOIS AND CESBRON). 


285 


in the various cases. It is evident that 
hemianopsia and scotoma are the two 
most important of these disturbances. 

As Dejerine pointed out, the condi¬ 
tion present is not, strictly speaking, a 
true hemianopsia, since its boundaries 
are practically never regular in outline, 
and the line marking off the blind from 
the unaffected portions of the visual 
field is never exactly vertical. True 
hemianopsia can exist only when the 
lesion, situated behind the chiasm, in¬ 
volves the visual pathways in that part 
of their course which extends from the 
decussation to the cerebral cortex. At 
the chiasm itself the nerve-fibers have 
not yet undergone complete separation 
into definite bundles, and it is here that 
we must seek an anatomical explanation 
for the irregular hemianopsia which ac¬ 
companies lesions of this portion of the 
optic pathway. 

Moreover, the most varied combina¬ 
tions of the several ocular disturbances 
may occur. A central scotoma, for ex¬ 
ample, may be present at first, hemia¬ 
nopsia then appearing (Pontoppidan), 
or hemianopsia may precede and be 
later supplemented with marked con¬ 
traction in the visual field (Striimpell). 
Hemianopsia and contraction are often 
found to coexist. 

Central scotoma is of very frequent 
occurrence, but does not seem to possess 
any special value as an indication of the 
lesion present, since it has been observed 
in cases where the visual tracts ap¬ 
peared to be crushed by the tumor, and 
it is difficult to understand how, under 
such conditions, the maculopapillary 
fibers could alone be affected. Indeed, 
from the variations in the extent of in¬ 
volvement of the visual fields no con¬ 
clusion can be reached with any degree 
of certainty as to the exact seat of the 
lesion. Changes in the visual fields are, 


however, almost constantly present; 
whenever examined for they have been 
found, and up to the present time 
Schonborn’s case is, perhaps, the only 
one in which they were wanting. This 
observer, moreover, fails to state 
whether he studied the color-perception 
in his patient or not. 

Among the changes in the eye-grounds 
in those suffering from tumors of the 
hypophysis, simple optic atrophy should 
receive first mention. Papillary edema, 
on the other hand, is of relatively rare 
occurrence. 

The uncommon occurrence of papil¬ 
lary stasis may be explained by the le¬ 
sions resulting from direct compression 
of the optic-nerve bundles. We can 
readily believe, with Terrien, that an in¬ 
timate union takes place very early be¬ 
tween the nerve-fibers and their sheaths 
in the visual tracts, and that the adhe¬ 
sions formed between these structures 
make it difficult, or even impossible, 
for the cerebrospinal fluid to enter 
the papilla. 

The pupillary reflexes in cases of hy¬ 
pophyseal tumor also afford an inter¬ 
esting study, in conjunction with the dis¬ 
turbances of vision already mentioned. 
In general, it may be said that they are 
always altered. 

In a large number of cases simple 
amaurosis is observed, with pupillary 
immobility as a consequence. Thus in 
a case reported by Selke (Inaug. Dis¬ 
sert., Konigsberg, 1891), the pupils did 
not react either to light or distance, 
though the patient could still distinguish 
light from darkness. In a case of un¬ 
usual interest, Berger observed during 
a period of temporary amaurosis loss of 
the reaction to light, while the reaction 
to distance was preserved. The light 
reflex later reappeared. In other cases, 
where the patients are still able to recog- 


286 


ACROMEGALY (LAUNOIS AND CESBRON). 


nize objects, the reflexes persist, but are 
less active. Yamaguchi has even wit¬ 
nessed very slow response to light in an 
eye showing normal visual acuity. 

Lastly, where hemianopsia exists, the 
hemiopic reaction may sometimes be ob¬ 
served. The well-known “hemianopsic 
pupillary reaction,” discovered by Wer¬ 
nicke, implies inability on the part of 
a visual field to bring about pupillary 
action in response to light falling upon 
it. The pupillary fibers of the optic 
nerve pass into the anterior corpus 
quadrigeminum; from here a relay of 
fibers starts which places them in con¬ 
nection with the nucleus of the pupil¬ 
lary sphincter, located in the central 
gray matter of the aqueduct of Sylvius, 
in the anterior portion of the common 
oculomotor nucleus. When these pupil¬ 
lary fibers are destroyed, as in cases 
where the optic tract has been crushed 
or has disappeared completely, the blind 
half of the visual field can no longer 
cause pupillary action. This reaction, 
then, is characteristic of an interruption 
in the optic fibers at a point between the 
chiasm and the corpora quadrigemina. 
The hemianopsic reaction of Wernicke 
is thus an integral part and almost ex¬ 
clusively an attribute of the syndrome 
resulting from disease in the hypophys¬ 
eal region. 

We must admit that the presence of 
this reaction does not appear to have 
been shown very often. While Josef- ~ 
sohn observed it very clearly, Gotzl and 
Erdheim, in a case of hemianopsia re¬ 
sulting from pituitary tumor, were un¬ 
able to find it. This failure and the 
dearth of confirmatory observations 
should, perhaps, be attributed to the dif¬ 
ficulties of technique which have to be 
overcome in order to demonstrate the 
existence of this singular pupillary dis¬ 
turbance, which is possessed of such 


great clinical value for the localization 
of brain lesions. 

Radiographic Study of the Cranium. 
—As for the positive signs of the pres¬ 
ence of a tumor of the hypophysis, they 
are afforded by X-ray examination of 
the cranium. 

No sooner had Roentgen’s discovery 
(1895) given us the power, as Giordani 
expressed it, “to make of the invisible 
an object” than the X-rays began to be 
utilized in the study of the skeletal dys¬ 
trophies, and of acromegaly in particu¬ 
lar. Marinesco brought out a compara¬ 
tive study of the bones of the hand in 
acromegaly of the massive and the giant 
types. The data collected by Gaston 
and G. Brouardel were sufficiently pre¬ 
cise to admit of the following conclu¬ 
sion, vis., that “radiographic studies of 
the acromegalic hand make it possible 
to trace the process of central bony re¬ 
absorption and the periosteal and carti¬ 
laginous proliferation which Pierre 
Marie and Marinesco observed in their 
histological studies.” 

To Beclere belongs the credit of hav¬ 
ing drawn from radiographic explora¬ 
tion the full measure of data to be de¬ 
rived therefrom in the study of the hy¬ 
pophyseal syndrome. His first attempts 
were fruitless because of an entirely 
abnormal thickening of the cranial 
bones, but his later researches, especially 
those carried out in cases sent him by 
us, were productive of more accurate 
results. He witnessed the simultaneous 
occurrence of three strongly character¬ 
istic changes: (o) A very irregular 
thickening of the cranial parietes: the 
outline of the skull, instead of being 
rounded, is polygonal; the external and 
internal tables, always separated by an 
abnormal space, alternately recede and 
come together, giving a moniliform ap¬ 
pearance on cross-section. (&) Exag- 


ACROMEGALY (LAUNOIS AND CESBRON). 


287 


gerated height and depth of the frontal 
and maxillary sinuses, (c) A more or 
less marked increase in the vertical, and 
especially in the anteroposterior, dimen¬ 
sions of the pituitary fossa, which, 
markedly altered, in most instances pre¬ 
sents the appearance of a cup. To these 
primary modifications must be added 
exaggeration of the postlambdoidal 
prominence (Papillaut, Launois, and 
Roy). 


increase in the size of the fossa can be 
plainly appreciated at its posterior wall. 
Schuller believes that enlargement of 
the bony cavity is the rule, even where 
the tumor is of relatively small size, and 
of slow, regular growth. The bony pa- 
rietes may, in certain cases, undergo 
pressure atrophy. In cases of rapidly 
growing tumor they likewise disappear, 
being invaded by the neoplastic tissue. 

Erdheim has established still nicer 



Diagram of the acromegalic skull, worked out by P. E. Launois and P, Roy, according to 
the X-ray findings of Boclere. Shows increased depth of frontal sinuses. Irregular thickening 
of the cranial bones, abnormal projection of postlambdoidal eminence, and enlargement of 
sella turcica. 


By combining the above data we were 
enabled to construct a diagram of the 
acromegalic skull, as shown in the an¬ 
nexed illustration. 

By taking X-ray pictures from the 
facial aspect one can likewise learn of 
the changes occurring in the mandible 
and the degree of prognathism they may 
engender. 

German investigators have sought to 
attain further precision in their radio- 
graphic studies. According to von Rut- 
keroski, each time the hypophysis in¬ 
creases in volume the sella turcica very 
rapidly enlarges in all dimensions; the 


distinctions. According to this author, 
if the tumor remains limited to the sella 
turcica, the latter enlarges, but its aper¬ 
ture above does not widen. If there is 
a, tumor of the infundibulum, the upper 
aperture may enlarge, but the bony fossa 
is little altered. Lastly, if the tumor 
rises above the sella turcica and bulges 
out over it, the fossa flares out above, 
presenting a broad superior opening. 
We may agree with Furnrohr (“Die 
Rontgenstrahlen im Dienste der Neu- 
rologie,” Berlin, 1906) and Sternberg, 
that these are altogether too fine dis¬ 
tinctions. All those who have had oc- 



288 


ACROMEGALY (LAUNOIS AND CESBRON). 


casion to study radio[,U'apliic prints will 
readily understand that it is practically 
impossible to appreciate the trifling dif¬ 
ferences of shading upon which such 
distinctions must depend. 



Jean-Pierre Mazas, the giant of Montastruc 


interior of the cranium, and that the 
borders of the sella turcica are clearly 
apparent. Normally a little cup-like 
cavity, it becomes so large, when a 
tumor of the hypophysis is present, that 



and back views). (.Brissaud and H. Meige.) 


It is, nevertheless, a fact that the 
diagnosis of tumor of the hypophysis 
cannot today be made without the 
assistance of the X-rays. If, taking 
advantage of the improved methods 
introduced by Beclere, we place in the 
stereoscopic apparatus a reduced image 
on glass, we find that the body of the 
sphenoid is brought out in relief in the 


the tips of two, three, or even more 
fingers can be accommodated in it. 

Relationship Existing Between Ac¬ 
romegaly and Gigantism.—The prob¬ 
lem concerning the relationship which 
gigantism bears to acromegaly is one 
of great interest. Our data are now 
sufficiently accurate to allow of its 
solution. 



ACROMEGALY (LAUNOIS AND CESBRON). 


289 


In his original description, Pierre 
Marie had clearly separated the two 
dystrophies. Numerous facts, however, 
were soon garnered which tended to 
overthrow this dualistic view. 

The question was in reality brought 
to a focus by Brissaud and Henri Meige 
(Jour, de med. et de <:hir. pratiques, 
Jan. 25, 1895; Nouv. Iconog. de la Sal- 
petriere, 1897. Meige, Congres de Neu¬ 
rol. de Grenoble, 1902, and Archives 
gen. de Med., Oct., 1902, p. 410. Bris¬ 
saud, Bull, de la Soc. Med. des Hop. de 
Paris, May 15, 1896) when they wrote: 
“The combination of acromegaly with 
gigantism is far from being a mere co 
incidence, a casual meeting between two 
distinct pathological states: Gigantism 
and acromegaly are one and the same 
disease. What has not been given suffi¬ 
cient consideration in their reciprocal 
relations, however, is the age at which 
the disease makes its first appearance. 

If the stage in which the bony over¬ 
growth occurs belongs to adolescence 
and youth, the result is gigantism and 
not acromegaly. If, later on, after hav- 
ing belonged to youth, in which the stat¬ 
ure is continually increasing, it en¬ 
croaches upon the period of completed 
development, i.e., upon that phase of 
life in which no further osteogenetic 
growth takes place, the result is a com¬ 
bination or concurrence of acromegaly 
with gigantism. 

“Gigantism is the acromegaly of the 
growing period; acromegaly is the gi¬ 
gantism of the period of completed de¬ 
velopment; acromegalogigantism is the 
result of a process common to gigantism 
and to acromegaly, overlapping from 
the period of adolescence into that of 
maturity.'’ 

These constitute three fundamental 
propositions, which soon received con¬ 
firmation from the labors of Woods, 

1—1 


Hutchinson and of one of us, published 
in conjunction with Pierre Roy. 

As viewed by the adherents of the 
unicist theory, acromegalic gigantism is 
that form of gigantism in which the 



Jean-Pierre Mazas. the gfiant of Montastruc 
(profile view). (Brissaud and H. Meige.) 


characteristic loss of harmony between 
structure and function finds its expres¬ 
sion, to a greater or less extent, in the 
usual symptoms and deformations of 
acromegaly, after union of the epiphy¬ 
ses to the diaphyses has taken place, 
whether this union has been prompt or 
delayed. 


290 


ACROMEGALY (LAUNOIS AND CESBRON). 


In the majority of giants almost all 
the stigmata of acromegaly may be 
recognized. Sometimes but slightly 
marked, the significant changes can be 
detected only upon careful inspection; 
at other times very pronounced, they 
attract immediate attention and are 


presence of acromegaly in the person 
before him. 

In the course of our investigations on 
gigantism we were led to establish a 
well-defined distinction between two 
types of giants, viz., the infantile giant, 
in whom the connecting cartilages have 



Acromegalogfigrantism in a Chinaman. {Matignon.) 


equally as striking as the stature of the 
individual afflicted with them. The dis¬ 
proportionate size of the hands and feet; 
the homely, sometimes even repulsive 
facial aspect; the evident sagging of the 
body, which is often marked, make of 
the subject’s gigantic stature a distinc¬ 
tion little to be envied, even in the eyes 
of the layman who cannot recognize the 


not undergone ossification and are still 
able to proliferate, and the acromegalic 
giant, in whom these cartilages have be¬ 
come ossified and who presents bony 
thickenings. This distinction, having as 
its anatomical basis the two separate 
processes of cartilaginous and perios¬ 
teal ossification, though a true one mor¬ 
phologically, does not hold good indefi- 










ACROMEGALY (LAUNOIS AND CESBRON). 


291 


nitely in time, i.c., the infantile type, 
having remained pure during a certain 
number of years, tends to progress 
toward the acromegalic type, later 
merging into it completely. We may 
state, as a general conclusion, that. 


tumor of the hypophysis can be recog¬ 
nized. In 10 cases, taken from among 
the most recent and the most thoroughly 
recorded we could find, it was not once 
lacking. To these direct observations 
should be added the results obtained 



Skull of the giant Constantin (profile view). {Dufrane and P. E. Launois.) 


while all giants are not acromegalics, 
at least all those who are not such al¬ 
ready are apt to become acromegalics. 

Whatever be the variety of gigantism 
encountered, a properly conducted clin¬ 
ical analysis will disclose the morbid 
manifestations of the hypophyseal syn¬ 
drome. That this is true is due to the 
fact that in all giants, whether in life 
by means of the X-rays, or after death 
on the autopsy table, the existence of a 


from studies of the skeletons of giants. 
Danger reports having found an in¬ 
crease in the length, breadth, and depth 
of the sella turcica in every case, and 
it is well known that in pathological 
states, as well as normally, the dimen¬ 
sions of this bony fossa in the sphe¬ 
noid are those best suited for its con¬ 
tents. 

The general conclusion warranted by 
all these mutually confirmatory data is 



292 


ACROMEGALY- (LAUXOIS AND CESBRON). 


that, whether associated witli-infaiitilism 
or acromegaly, gigantism always occurs 
in association with a tumor of the hy¬ 
pophysis. This assertion cannot, of 
course, be given as applying to all future 
observations, but in view of its uniform 


acromegaly with or without giantism. 
That the relationship between acro¬ 
megaly and giantism is close is 
shown by the fact that a consider¬ 
able percentage of acromegalics are 
giants and that a still larger percent¬ 
age of giants develop acromegaly. 


Skull of the gfiant Constantin (anterior view). 


(Dufrane and P. E. Launois.) 



confirmation by those of the past it is, 
at least, very impressive. 

Hyperactivity of the anterior lobe 
of the pituitary coming on before the 
completion of epiphyseal ossification, 
results in giantism, that is to say, the 
individual is overgrown but well 
proportioned. After epiphyseal ossi¬ 
fication is complete, however, hyper¬ 
activity of the hypophysis results in 


Symmers (Interstate Med. Jour,, 
Nov., 1917). 

COURSE AND DURATION.— 

Established acromegaly is generally 
observed in adults, male or female. 
The initial dystrophic phenomena ap¬ 
pear at the age of 18 to 25 years, i.e., 
at the period in which, under normal 
conditions, growth is continued and 


ACROMEGALY (LAUNOIS AND CESBRON). 


293 



Base of cranium of the giant Constantin, showing marked enlargement ot sella 
tuicica. {Dufrane and P. E- Launois.) 


for these changes. In women the 
outset of the disease may be traced 
with some degree of probability to a 
period at which menstruation became 
irregular or ceased. We must recognize 
that such indications are rather vague, 
as is also the information obtained from 
the past morbid history. Sometimes in¬ 
fectious diseases are found to have ex- 


The dystrophy seems to occur with 
greater frequency in women than in 
men. Taking the combined statistics of 
Souza-Leite and of Duchesneau, we find 
22 men were affected as against 31 
women. 

While the onset of the disease is 
sometimes delayed (forty-nine years in 
a case of Schwartz), it can also be pre¬ 


completed. Sometimes it is headache 
which leads the subject to consult a 
physician. Other victims, frightened 
at seeing their hands and feet grow 
larger, come to find out the reason 


isted, and under these conditions the 
question arises in our minds whether 
they could not have created a disturb¬ 
ance in the hypophysis, as well as in the 
other ductless glands. 




294 


ACROMEGALY (LAUNOIS AND CESBRON). 


cocious, and the few cases of this kind 
recorded have made it possible to de¬ 
scribe the acromegaly of children or 
of adolescents. 

Race is without influence in the etiol¬ 
ogy. Acromegaly has been met with in 
all countries and among all races. Di- 



Humerus of the giant Constantin. Absence 
of union of upper epiphysis at the age of 29 
years. {Dufrane and P. E. Launois.) 


rect hereditary transmission has been 
observed. 

The dystrophy follows a progressive, 
but extremely slow course, which can 
be divided into several stages. The first 
(stage of onset), in which the deformi¬ 
ties begin to develop, is followed by a 
second (sthenic stage), in which they 
attain their maximum. In this stage 
the acromegalic woman presents a most 
striking appearance. The increased size 


of her body, accentuated by hypertro¬ 
phy of the extremities; her peculiar 
countenance, with the lips, chin, and 
cheeks frequently covered with long, 
curly hair, and her low-pitched voice, 
all combine to impart a masculine ap¬ 
pearance, which is sometimes very pro¬ 
nounced. In a third stage the hypo¬ 
physeal syndrome asserts itself until its 
manifestations are more or less com¬ 
pletely present. 

The duration of the disease varies 
within wide limits (twenty to thirty 
years). In this connection Sternberg 
recognizes three forms of the affection: 
an ordinary form, running its course in 
eight to thirty years, and two rare 
forms, the one benign, which may last 
fifty years,, the other malignant, des¬ 
troying life in three to four years. 
This last form, seen only 6 times out 
of 210 cases, is always associated, ac¬ 
cording to Gabler, with an epithelial 
tumor of the hypophysis. 

PROGNOSIS. —As for the termina¬ 
tion, it is fatal. The patient at last in¬ 
variably succumbs, either to the effects 
of a slowly developing cachexia, to in¬ 
tercurrent disease, or suddenly succeed¬ 
ing an attack of syncope or some cere¬ 
bral accident. 

If acromegaly be associated with in¬ 
fantile gigantism, the data at hand are 
somewhat more precise, and the onset 
of the disease can readily be referred to 
the growing period proper. 

DIAGNOSIS. —The external appear¬ 
ances of acromegalics are so character¬ 
istic that the diagnosis is at once rflani- 
fest, even from a distance. There are 
a few disorders, however, with which 
acromegaly might be confounded, and 
which it is necessary to differentiate. 

In myxedema, the trunk and extremi¬ 
ties show enlargement, which consists, 
however, merely of an edematous infil- 



ACROMEGALY (LAUNOIS AND CESBRON). 


295 


tration of the soft tissues. The thick¬ 
ened skin is bound down to the sub¬ 
jacent layers and merges into them. 
The round,puffy face of myxedema dif¬ 
fers radically from the ovaloid face of 
the acromegalic patient, in whom, be¬ 
sides, prognathism and kyphosis are 
characteristic features. 

In Paget’s disease of the bones (oste¬ 
itis deformans) there is increased thick¬ 
ness of the cranial bones and more or 
less marked bowing of the bones of the 
extremities. The thickened femora and 
tibia are strongly curved inward and 
forward, the legs are widely separated, 
and the trunk and neck are fixed in a 
position of pronounced flexion. In this 
affection the bones of the cranium are 
those involved, whereas in acromegaly 
the facial bones are rather affected. In 
the limbs the changes are limited to the 
diaphyses of the long bones, whereas 
acromegaly shows a marked predilec¬ 
tion for the bones of the extremities 
and the extremities of these bones. 
Paget’s disease, moreover, seldom ap¬ 
pears before the age of 40, and, differ¬ 
ently from acromegaly, attacks the va¬ 
rious bones without order or symmetry. 

Under the name of leontiasis ossea 
Virchow described a condition associ¬ 
ated with hyperostosis of the facial and 
cranial bones. The lumpy appearance 
of the exostoses and the normal propor¬ 
tions of the hands and feet are sufficient 
to preclude all doubt as to the nature of 
the affection. 

In erythromelalgia the face remains 
unchanged. The hypertrophic process 
involves only the soft tissues of the feet 
and hands, and is associated with an al¬ 
together peculiar cyanotic hue of the 
integument. 

Certain cases presenting a combina¬ 
tion of the stigmata of rickets and of 
the lymphatic diathesis might be taken 


for acromegalics. They exhibit clumsy 
hands and large feet, the lower lip is 
thickened and everted, and the face is 
somewhat puffy. But the extremities 
show nodal deformities of a special 
type, while prognathism, as well as 
macroglossia, are completely absent. 

It is in hypertrophic pidmonary osteo¬ 
arthropathy, the dystrophic affection 
seen among inveterate coughers, that 
confusion with acromegaly most readily 
arises. 

Pierre Marie, who was the first to 
recognize and describe this form of sys¬ 
tematized osteopathy, showed clearly, 
in a striking comparison he made of 
the two conditions, that the features 
wherein they differ are more numerous 
than their points of similarity. In both 
affections there is symmetrical hyper¬ 
trophy of the upper and lower extremi¬ 
ties, together with spinal curvature. 
But in pulmonary osteopathy, the hyper¬ 
trophy, which is not uniformly distrib¬ 
uted, is associated with distinct deform¬ 
ity of the parts affected. The spinal 
curve is altogether different from that 
of acromegaly, and prognathism is ab¬ 
sent. The changes are strictly confined 
to the bony tissues. In the hands, the 
distal phalanges are clubbed, resembling 
drumsticks; the nails are lengthened, 
broadened, curved like a parrot’s beak, 
and show cracks and longitudinal stria- 
tions. 

The carpal and metacarpal regions 
are practically normal. The wrist, how¬ 
ever, is thickened and greatly deformed. 
In the feet, the distal phalanges are 
clubbed, the tarsus and metatarsus rel¬ 
atively normal, and the malleoli hyperr 
trophied in all dimensions to such an 
extent that the lower part of the leg 
is thicker than the middle. In ad¬ 
dition, all the long bones of the limbs 
are thickened, though more markedly 


296 


ACROMEGALY (LAUNOIS AND CESBRON). 


in the leg and forearm than in the thigh 
and arm. The joints are involved in 
these changes; their enlargement inter¬ 
feres with ease of motion, both active 
and passive. Furthermore, kyphosis is 
not constantly present, and when it is 
present is confined to the lower dorsal 
or lumbar regions. In the face, the su¬ 
perior maxillary bone is alone thick¬ 
ened, the mandible remaining normal. 

In syringomyelia of the pseudoacro¬ 
megalic type, the hypertrophic process 
is confined to the upper limbs and some¬ 
times to a single extremity. It does not 
involve equally all the fingers of a hand. 
The parts involved are deformed and 
exhibit more or less marked trophic 
changes. The symptoms resulting from 
the spinal cord lesion are easily recog¬ 
nized. 

As for certain localized hypertrophic 
manifestations (macrodactylia, macro¬ 
podia, hypertrophy of a limb, or of one 
side of the body), described by Virchow 
under the name of partial acromegaly, 
they are congenital in most instances 
and bear no relationship to true acro¬ 
megaly. 

PATHOLOGY. —The dystrophic 
process in acromegaly shows a special 
predilection for the supporting tissues 
derived from the mesoderm (connect¬ 
ive tissue, cartilage, and bone), to what¬ 
ever degree of differentiation they may 
have attained. 

The thickening of the integument is 
due to marked proliferation of its con¬ 
nective-tissue elements; the prolifera¬ 
tion takes place in each of its various 
layers. Hyperplasia in the superficial 
stratum brings about hypertrophy of 
the papillae, causing them to appear as 
pronounced ridges. Similar connective- 
tissue proliferation takes place in the 
walls of the sebaceous and sweat glands, 
in the sheaths of the hair-follicles, in 


the adventitia of the superficial blood¬ 
vessels, and in the nerve-sheaths. These 
vascular and nervous changes are not 
without influence on the trophic state 
and functions of the skin. They like¬ 
wise interfere with the nutrition of the 
cutaneous appendages. The epidermis 
develops many new layers, especially in 
the zone of the stratum corneum; the 
several varieties of hair become thick¬ 
ened and kinked, and the nails develop 
longitudinal striations. Hypertrophy of 
the teeth has occasionally been noticed. 

The connective-tissue cells of the sub¬ 
cutaneous panniculus adiposus in . some 
cases become overloaded with fatty ma¬ 
terial. To this superficial adipose de¬ 
posit is added, in the syndrome identi¬ 
fied by Frohlich, a deep-seated adipose 
accumulation, especially marked in the 
neighborhood of the peritoneal reflec¬ 
tions. 

Macroglossia is due not only to thick¬ 
ening of the mucous covering layer of 
the tongue, but also to abnormal growth 
of the interstitial connective tissue. The 
nasal, pharyngeal, laryngeal, and tra¬ 
cheal mucous membranes are likewise 
the seat of marked proliferation of the 
connective-tissue elements. 

The alterations occurring in the fleshy 
portions of the muscles must also be 
attributed to changes of this kind. 
Thickening of their sheaths and of the 
septa dividing them into bundles brings 
about a marked increase in their size. 
Microscopically, proliferation of the nu¬ 
clei and atrophy of the contractile sub¬ 
stance are observed. The hypertrophic 
process extends to the tendons,of which 
the inserting surfaces become broader, 
and to the aponeurotic expansions. 

Among all the changes which the sup¬ 
porting tissues undergo, the most char¬ 
acteristic, as well as the most marked, 
are those involving the skeleton; they 



Molds of the Upper Extremities of a Case of Acromegaly. (P. E. Launois.) 













ACROMEGALY (LAUNOIS AND CESBRON). 


297 


are the result of a disturbance in the 
process of periosteal bone formation. 

They are met with in the bones hav¬ 
ing marrow cavities, and are confined 
to those of the extremities and those of 
cancellous structure. They are also 
found in those membranous bones 
(cranial bones, inferior maxillary bone) 
which develop directly from the con¬ 
nective tissues, without being preceded 
by cartilage. 

Whereas in adult life the periosteum 
ordinarily ceases to be productive ex¬ 
cept under certain experimental or trau¬ 
matic conditions, of which a detailed 
analysis was made by Ollier, in acro¬ 
megaly it is seen to proliferate and pro¬ 
duce increased thickness of the bones 
by laying down new osseous layers. 
Pierre Marie and Marinesco (Archives 
de Med. Exper. et d’Anat., p. 539, 
1891), Renaut and Duchesneau, have 
made studies of the histological changes 
occurring in this abnormal type of os¬ 
teogenesis. The process is described as 
“a slow growth of certain bones, taking 
place at the expense of the periosteal 
bone, which is reduced to thin layers, 
while the bony tissue of medullary 
origin gains in prominence, continues 
to develop with, so to speak, mathemat¬ 
ical regularity, and comes to occupy a 
predominant position in the structure of 
the bone. On transverse section the en¬ 
tire area is occupied by red bone-mar- 
row, containing more or less numerous 
fat-cells. The vessel supplying each 
medullary space is located exactly in 
Its center and appears in cross-section. 

. . . At the periphery of the bone- 

marrow, in the neighborhood of the 
open areas corresponding to the giant 
Haversian spaces of cancellous bone- 
tissue, the rows of osteoblasts and mul- 
tinuclear cells which are seen in rachitic 
bones are here conspicuously absent.’' 


Summarizing the above, we may state 
that, whereas new layers are being 
added at the periphery of the bone, the 
central portion is undergoing actual re¬ 
sorption by the osteoclasts, the marrow 
proliferating to take its place. Recently 
Presbeanu (These de Paris, 1909) had 
the opportunity, in a case of acromegaly 
that died as the result of a fall causing 
multiple fractures, to note the existence 
of marked demineralization of the 
bones; the proportion of ash, which nor¬ 
mally ranges between 50 and 80 per 
cent., had been reduced to 36 per cent. 
These chemical changes may well ac¬ 
count for the weakened condition of the 
skeleton in this disease. 

In infantile giants undergoing transi¬ 
tion into acromegaly, the changes in the 
bones coexist with an altogether abnor¬ 
mal persistence of the cartilages uniting 
the epiphyses of long bones to their di- 
aphyses. In these cases the bones, 
while growing in thickness, also increase 
in length, at least for a certain period. 

The articulating surfaces of the bones 
become broader, and the cartilaginous 
tissues covering them spread out with¬ 
out losing in depth. They may undergo 
some slight alterations in structure, re¬ 
calling those seen in the early stages of 
certain arthropathies. 

As for the changes occurring in the 
cardiovascular system, though less 
plainly evident than those already dis¬ 
cussed, they are, nevertheless, well 
marked. The thickening of the vessel 
walls and cardiac hypertrophy are due 
to hyperplasia of the connective-tissue 
elements they contain. The cardiac 
muscular fibers may be more or less al¬ 
tered. 

Enlargement of the heart, either 
simple or associated with a myocar¬ 
ditis, is the condition usually found 
in acromegaly. Sclerosis of the ar¬ 
teries and degenerative lesions affect- 


298 


ACROMEGALY (LAUNOIS AND CESBRON). 


ing the walls of the veins, with dila¬ 
tation and subsequent obliteration of 
their lumen, are constantly present 
These changes in the heart and ves¬ 
sels should be considered as much a 
part of the clinical picture as the 
■changes in the bones, and they are 
probably due to the prolonged hyper¬ 
tension of the vessels, the result of 
hypersecretion of the pituitary body. 
Phillips (Med. Rec., Feb. 20, 1909). 

The spleen and lymph-nodes some¬ 
times appear sclerosed, so greatly has 
their connective-tissue network become 
thickened. 

In a few cases a more or less general¬ 
ized condition of splanchnomegaly has 
been reported, constituting a genuine 
gigantism of the viscera. 

The kidneys, spleen, and pancreas 
had, in a few of these cases, doubled or 
even tripled in size. 

Atrophy of certain viscera, e.g., of the 
kidney, has been recorded in a few 
cases; the appearance of the renal cor¬ 
tex recalled that commonly found in in¬ 
terstitial nephritis. 

In the nervous system the connective- 
tissue proliferation already manifested 
in the finer peripheral divisions then ex¬ 
tends to the deeper branches of the 
nerves, which present the appearance of 
thick cords. The sympathetic nerve 
branches, and more especially the in¬ 
ferior cervical ganglion, have been 
found enlarged and sclerosed. 

In a case studied by Duchesneau, the 
peripheral nerves showed changes due 
to pressure exerted on the spinal roots 
at the intervertebral foramina. In that 
of Sainton and State there was bony in¬ 
filtration of the dura, with the forma¬ 
tion of calcareous deposits on its inner 
surface, transforming it, in the dorsal 
and lumbar regions, into a veritable 
tube of lime. 

The spinal cord has occasionally been 
found the seat of connective-tissue pro¬ 


liferation and localized or more or less 
widespread sclerosis. 

In the brain, the neuroglia, which is 
also one of the group of supporting 
tissues, may proliferate more or less 
actively. 

The Hypophysis.—Among the 
changes taking place in the intracranial 
structures, the most interesting, as well 
as the most important, are those involv¬ 
ing the hypophysis. 

Connected by a partially hollow stalk 
with the base of the brain, molded into 
the sella turcica, which it almost com¬ 
pletely fills, held in position by, a dia¬ 
phragm of dura mater centrally perfo¬ 
rated, and weighing on the average 0.5 
gram [7^ grains] in adults, the hy¬ 
pophysis has long been considered an 
ancestral remnant, a rudimentary organ 
of no importance. 

According to one of us, the anterior 
or epithelial lobe of the hypophysis is 
a gland of branched tubular type. The 
epithelial tubes or cords of which it is 
composed undergo anastomosis. In the 
spaces between them run very broad 
capillary blood-vessels, with very thin 
endothelial walls, which must be con¬ 
sidered as the excretory ducts. The 
glandular cords are made up of epithe¬ 
lial cells loaded with granulations. In 
view of the different staining affinities 
shown by the latter, the cellular ele¬ 
ments containing them may be divided 
into three classes: 1, acidophile cells, 
which may be eosinophiles, fuchsino- 
philes, or aurantiophiles; 2, basophile 
cells, sometimes called cyanophiles; 3, 
chromophobe cells. The protoplasm of 
these cells is always acidophile. It con¬ 
tains, except in the case of the young 
acidophilic forms and the chromo¬ 
phobes, zymogenic granulations, which 
infiltrate the epithelial elements of the 
glands. In addition to their acidophilic 


ACROAIEGALY (LAUNOIS AND CESBRON). 


299 


property, the intracellular granulations 
possess in common the property known 
as siderophilia. 

The primordial cell of the pituitary 
gland, from the morphological as well 
as the embryological standpoint, is a 
small eosinophilic cell with compact nu¬ 
cleus and small protoplasmic body, de¬ 
void of granulations. This cell develops 
along two different lines and produces 
either an acidophilic and siderophilic se¬ 
cretion or a basophilic secretion. Two 
distinct series of cells, therefore, exist 
in the hypophysis: an eosinophilic se¬ 
ries, which becomes siderophilic, and an 
eosinophilic series, which becomes baso¬ 
philic. The products elaborated by 
them having been eliminated by a semi- 
holocrine process, the cells of both series 
become chromophobic cells, which are 
capable of undergoing regeneration and 
of renewing their functional activity. 
The secretory product of the hypophy¬ 
sis is a colloid substance, giving reac¬ 
tions sometimes acidophilic, at other 



X-ray of base of an acromegralic cranium, showing: 
enlargfement of sella turcica. ( Ch. Infroit.) 


times basophilic, and which presents 
analogous features with the material 
contained in the alveoli of the thyroid 
gland. We have thought it proper to 
introduce a summary of this cytologic 


study, based on our own researches, be¬ 
lieving that it may serve as a basis for 
pathological studies, the results of 
which thus far have been indefinite and 
inconstant. 



Tumor of the pituitary from the gfiant 
Santos. {Dana.) 


On the basis of facts discovered on 
the autopsy table, which today usually 
receive confirmation from radiographic 
studies of the skull during life, we are 
able to assert,as we have already shown, 
that hypertrophy of the hypophysis is 
the rule in acromegaly. 

We desire to call attention to the fact 
that in a number of these negative cases 
the tumor did not originate in the hy¬ 
pophysis itself; that this gland was 
simply compressed or destroyed, and 
that in a few cases the histological de¬ 
scriptions were decidedly lacking in 
completeness. We must admit, never¬ 
theless, that certain of the facts at hand 
leave room for doubt, which will have 
to be dispelled by future observations. 

The gross features of tumors of the 
hypophysis vary. The size ranges from 
that of a cherry up to a hen’s egg or 





300 


ACROMEGALY (LAUNOIS AND CESBRON). 


mandarin. The sella turcica varies sim¬ 
ilarly in its dimensions; its clinoid proc¬ 
esses recede from one another, become 
blunted, and, where an infiltrating neo¬ 
plasm is present, sometimes disappear 
entirely, together with the bony parti¬ 
tions they surmount. 

The tumor not infrequently projects 
beyond the limits of the bony fossa, not- 


lial origin, may be variously modified 
according to the type of neoplasm pres¬ 
ent, which may be sarcomatous, angio¬ 
matous, etc. 

The minute structure of tumors of 
the hypophysis has been variously in¬ 
terpreted. The diversity of the descrip¬ 
tions given of it results chiefly, if not 
entirely, from the uncertainty which 



Tumor of the pituitary body extending into the right lateral ventricle. 
(P. E. Launois.) 


withstanding the increased size of the 
latter; it bulges toward and indents the 
lower surface of the cerebrum, and may 
even infiltrate it to a considerable depth. 

In color the growth is usually gray¬ 
ish, sometimes yellowish; its external 
surface, often granular in appearance, 
may be dotted with small, reddish areas, 
representing dilated vessels or even true 
hemorrhagic foci. In consistency it is 
soft and more or less friable. On com¬ 
plete transverse section more or less 
extensive pockets of colloid material 
having a gelatinous appearance may be 
revealed. 

These general features, which belong 
more particularly to tumors of epithe- 


prevailed until within the last few years 
as to the normal structure of the gland. 

It seems to have been shown, how¬ 
ever, that, in a number of the cases re¬ 
ported, the tumor was epithelial in 
origin. From the 57 cases collected by 
him, Parona has obtained the following 
percentages:— 

Adenosarcoma.45 per cent. 

Adenoma.26 “ “ 

Sarcoma.19.4 “ “ 

Angioma.3.4 “ “ 

These figures, together with similar 
statistics already published, should be 
taken with some reserve, and we must 
recognize, with Hanau, that the condi¬ 
tion of difluse hypertrophy of the pitui- 







ACROMEGALY (LAUNOIS AND CESBRON). 


301 


Cyanophile 

Series. 


Acidosiderophile 

Series. 



PrUnordial eosinophile cell witlwat yranula- 
liuiis. 



Slightl}/ granular 
cyanophile cell. 





Granular eosinophile 
cell. 


Markedly granular 
cyanophile cell con¬ 
taining fat. 




i 


I 




Siderophile cell containing 
siderophilic colloid secre¬ 
tion. 



liesidual chromophobe cell destined to undergo regeU' 
eration. 


The two series of secreting: cells found in the hypophysis, according: to the 
researches of P. E. Launois. 





302 


ACROMEGALY (LAUNOIS AND CESBRON). 


tary bears a marked resemblance to sar¬ 
coma. 

A few of the descriptions, however, 
embody cytological details sufficiently 
definite to be of value. Among them 
may be mentioned the observations of 
Benda, who found, in three instances, 
that the hypertrophy was due to pro¬ 
liferation of the chromophile cells, i.e., 
the functionally active elements of the 
gland. In a fourth case, the neoplasm 
was undergoing regression.. Hyperpla¬ 
sia of the same cells has likewise been 
observed three times by Vassale. Lewis, 
in an acromegalic case which succumbed 
to cerebral hemorrhage soon after the 
onset of the dystrophy, found a pitui¬ 
tary which, while normal in macro¬ 
scopic appearance, contained numerous 
large chromophilic cells. 

Stucl}^ of several cases led the 
author to conclude that pituitary 
tumors of the adenoma type with 
cells that do not take the acid 
stains did not induce a tendency to 
acromegaly, while the latter was 
practically always present when the 
cells were acidophile. Kahlmeter 
(Hygeia, Ixxviii, No. 10, 1916). 

Enlargement of the hypophysis may 
also result from exaggerated growth of 
its connective-tissue network. Under 
such conditions the stage of hyperplasia 
of the organ, associated with expansion 
of the sella turcica, may be followed by 
a stage of sclerotic atrophy. The en¬ 
larged bony cavity does not resume its 
former size and appears too capacious 
for the gland inclosed in it. This condi¬ 
tion was found in a case of Huchard, in 
which the autopsy was performed by 
one of us. 

Instead of being generalized through¬ 
out the glandular parenchyma, the neo¬ 
plastic process may be localized and ap¬ 
pear in the form of more or less volum¬ 
inous masses (partial adenomas, cysts). 


reaching a variable size [Widal, Roy, 
and Froin (Revue de Med., Apr. 10, 
1906)]. 

From a general review of the facts 
yielded by recent investigations, the tend¬ 
ency has arisen to accept the conclu¬ 
sion that the hyperplastic condition of 
the hypophysis observed in acromegaly 
is dependent upon an increase in the 
number and size and an exaggerated 
functional activity of the chromophilic 
cells. This assertion, however, which 
to us appears premature, cannot, at 
present, be unreservedly accepted, for 
a few cases have been seen in which the 
hypophyseal lesion was not accompa¬ 
nied by any dystrophic disturbance. 

In acromegalic gigantism tumors of 
the hypophysis are more constantly 
present than in simple acromegaly. We 
have already stated, indeed, that in the 
former condition they have never been 
found wanting. As for their histolog¬ 
ical structure, the same uncertainty pre¬ 
vails. 

To complete this study, we shall men¬ 
tion the alterations which the other 
ductless glands may undergo in acro¬ 
megaly :— 

With reference to the thyroid, Hins¬ 
dale, in a series of 36 cases collected 
from the literature, found hypertrophy 
13 times, atrophy 11 times, while in 12 
cases the gland appeared to be normal. 

Klebs, Massalongo, and Mosse have 
reported hypertrophy or regeneration of 
the thymus gland. Most observers have 
failed to inquire into the condition of 
the adrenals. Their study might prove 
fruitful, in view of the opinion of Sa- 
jous that these organs take an active 
part in the morbid process. 

PATHOGENESIS.—According to 
Klebs, who had witnessed persistence of 
the thymus in a case of acromegaly, the 
afifection is due to an unusual state of de- 


ACROMEGALY (LAUNOIS AND CESBRON). 


303 


velopment of the vascular system, and 
results from an angiomatous condition 
of the thymus. According to this view, 
the thymus produces endothelial ele¬ 
ments which, swarming through the ves¬ 
sels, assume the role of formative cells 
in the production of fresh vessels. Thus 
there would result an increase in the 
number of vascular channels, and, in 
consequence, hypernutrition and aug- 



states, at the age when growth ceases, 
i.e., between the 20th and 25th years. 
If their functions continue after that 
age has been passed, acromegaly results. 

Freund and Verstraeten attribute the 
dystrophy to a reversal in the normal 
order of events occurring in sexual de¬ 
velopment. ‘Tn a certain number of 
individuals,” writes Freund, “the ordi¬ 
nary mode of develoonient is disturbed. 



Cellvilar characteristics of a tumor of the pituitary. (P, E. Launois, 


mentation in size of the terminal por¬ 
tions of the body, i.c., of those regions 
of the organism in which the flow of 
blood slackens its speed. This power 
to form new vessels, however, which 
he attributes to the thymus, is as yet 
lacking in proof. 

Massalongo has taken up Klebs’s the¬ 
ory and modified it. He believes acro¬ 
megaly to be due to persistence of the 
functions of the thymus and the hypoph¬ 
ysis—organs which play an impor¬ 
tant part during fetal life. Normally, 
these glands undergo retrogression, he 


Either it lags behind the norm, or else 
it advances beyond the norm, both in 
time and in space [i.e., morphologic¬ 
ally] ; the malformations which result 
go hand-in-hand with the disturbance 
in the development of puberty, and 
later, too, of the sexual functions.” It 
is certain that the development of the 
genital apparatus is not without influ¬ 
ence on that of the osseous system, and 
one of us, in a series of communica¬ 
tions, has described the alterations pro¬ 
duced in the bones by congenital atro¬ 
phy of the testicles, of the ovaries, and 















304 


ACROMEGALY (LAUNOIS AND CESBRON). 


by castration before puberty. Now, the 
frequency with which disturbances of 
the genital functions are associated with 
acromegaly has long been noticed. But 
how is the influence they may exert on 
the growth of the skeleton to be ex¬ 
plained ? Perhaps by their suppression, 
diminution, or modification of a secre¬ 
tory product having as its purpose, 
as suggested by Sajous, to activate 
the oxidation of phosphorus-containing 
substances. 

In short, the development of the geni¬ 
tal functions having some influence on 
that of the skeleton in general, disturb¬ 
ances in these functions may be factors 
in the production of acromegaly, but 
they do not appear to be sufficient to 
bring on the dystrophy of themselves. 

In the opinion of Recklinghausen and 
Holschewnikow, acromegaly is merely 
a trophoneurotic affection, dependent 
upon changes in the central and pe¬ 
ripheral nervous system. Disturbances 
involving the vasomotor nerves would, 
according to this view, lead to over¬ 
nutrition and hypertrophy of the ex¬ 
tremities. There is nothing to indicate, 
however, that the nervous changes in 
this dystrophy are primary. The case on 
which these two observers based their 
opinion was one of syringomyelia. 

Pierre Marie looks upon acromegaly 
as ‘'a kind of systematized dystrophy, 
occupying in the nosological scale a po¬ 
sition about corresponding with that of 
myxedema, and bearing to an organ of 
trophic function (the hypophysis) as 
yet unknown relations similar to those 
which unite niyxedema and cachexia 
strumipriva to certain lesions and re¬ 
moval of the thyroid gland.” 

As this quotation shows, it was the 
sponsor of acromegaly himself who was 
the first to suspect the functional role 
of the hypophysis, “that enigmatic or¬ 


gan,” as Van Gehuchten termed it not 
so many years ago. 

In the preceding pages we have suffi¬ 
ciently dwelt upon the frequency, and 
even constancy, with which hypertrophy 
of the hypophysis, especially of epithe¬ 
lial origin (adenoma), is present in 
acromegaly. We pointed out, likewise, 
a condition which is daily receiving con¬ 
firmation from X-ray studies, viz.: that, 
whatever be the mode of progression of 
the dystrophy, whether it take expres¬ 
sion in its sthenic phase as the pure 
acromegalic type of Pierre Marie, or 
the lipomatous type of Frohlich, there 
is present in most cases enlargement of 
the sella turcica, which serves to indi¬ 
cate hypertrophy of the pituitary body. 
In view of these facts, while recognizing 
to their full value the negative cases so 
far recorded, we are completely in favor 
of the hypophyseal theory. 

Having reached this conclusion, we 
still have to solve two other phases of 
the problem, viz.: to ascertain the na¬ 
ture and mode of action of the disor¬ 
ders affecting the function of the hy¬ 
pophysis, and to find out whether these 
disorders are sufficient in themselves, or 
whether it is not necessary to invoke 
the synergistic functions of the other 
ductless glands as participating in the 
disturbance. 

The experiments of physiologists, an 
excellent analysis of which has been 
given by Paulesco (L’hypophyse du cer- 
veau, Paris, 1908), have yielded, it must 
be said, no definite results. Practised 
upon young or old animals, removal of 
the hypophysis produced no skeletal dis¬ 
orders nor acromegalic manifestations. 
This dearth of results is not surprising 
when we consider, on the one hand, the 
comparatively short period of survival 
of the experimental animals, and, on 
the other, the serious traumatism to 


ACROMEGALY (LAUNOIS AND CESBRON). 


305 


which they had been subjected in the 
operations. Of greater weight, as we 
have already emphasized, are the data 
afforded by the clinicopathological 
method. It is on the basis of these data 
that investigators have sought to ascer¬ 
tain the functions of the hypophysis, 
and, in particular, its trophic role. 

Some authors, among them Tansk 
and Vas, and Parhon, consider acro¬ 
megaly to be the result of excessive 
functionation on the part of the pitui¬ 
tary—a genuine hyperhypophysia. Ac¬ 
cording to others, the functional role of 
the gland is to destroy substances toxic 
to the nervous system. The accumula¬ 
tion of these substances, in the presence 
of functional disturbance of the hy¬ 
pophysis, would produce, because of spe¬ 
cial predisposition, a continual state of 
irritation, resulting in hyperplastic 
changes in the bony and other support¬ 
ing tissues, primarily and chiefly notice¬ 
able in the extremities. The acromeg¬ 
alic deformities would be an expression 
of functional insufficiency of the organ, 
or hypohypophysia. 

The above hypotheses were those 
most generally accepted when Hochen- 
egg published the results of his opera¬ 
tions of hypophysectomy. The steady 
retrogression of the manifestations of 
acromegaly witnessed after excision of 
hypophyseal tumors affords an argu¬ 
ment of the first importance in favor of 
the theory of glandular hypersecretion. 
Future observations will soon bring fur¬ 
ther confirmatory evidence. 

The facts recorded by Hochenegg 
have also lent considerable support to 
the doctrine of the synergistic func¬ 
tional relationship existing between the 
ductless glands. In one of his cases, 
menstruation, which had long since 
been arrested, returned and was main¬ 
tained at regular intervals. In 2 cases 


removal of the hypophysis was followed 
by hypertrophy of the thyroid. We 
have already stated that at the autopsy 
of acromegalics hyperplasia of one or 
more ductless glands is frequently 
found. Furthermore, it is well known 
that the sexual glands exert a distinct 
influence on the osteogenetic activities of 
the connecting cartilages, and that thy¬ 
roid extract is possessed of an analo¬ 
gous action. Caselli has expressed his 
belief in the identity of the functions of 
the hypophysis and thyroid, basing his 
opinion on the experimental observation 
that removal of the hypophysis acts on 
tetany parathyreopriva in the same 
manner as does removal of the thyroid. 
This functional identity, as Souques 
(“Acromegalie” in‘Traite de Medecine” 
of Charcot and Bouchard, 2d ed., vol. x, 
p. 490) terms it, or, better, this func¬ 
tional analogy, would furnish an ex¬ 
planation for the power of mutual sub¬ 
stitution of function exhibited by these 
glands under pathological conditions. 

It was through surgery, practised for 
curative purposes, that the functions of 
the thyroid were revealed to us; it is 
through surgery that today the role of 
the hypophysis is being disclosed. It is 
to surgery, again, that we shall in the 
future be indebted for the acquisition of 
positive data which will enable us to 
solve the absorbing problem concerning 
the synergistic functional relationship 
of the ductless glands. 

TREATMENT. —The treatment of 
acromegaly necessarily remained, for a 
long time, purely symptomatic, and was 
limited to combating the most distress¬ 
ing manifestations, such as pain and in¬ 
somnia. Agents modifying general nu¬ 
trition, such as iodine and arsenic 
(Campbell), were then brought into 
use. Iron in large doses and hot baths 
were said to have given distinct relief 


306 


ACROMEGALY (LAUNOIS AND CESBRON). 


in a case under the care of Brissaud. 
Schwartz claimed to have obtained 
beneficial effects from the use of 

ergot. 

As a corollary to the discoveries of 
Brown-Sequard, opotherapic medica¬ 
tion was resorted to. Warda and Pirie 
tried thyroid treatment without suc¬ 
cess, though Lyman Greene claimed 
good results with it. Napier admin¬ 
istered powdered ovary to an acrome¬ 
galic woman without benefit. Kuh, 
advocates pituitary substance. 

In a case of acromeg'aly with psy¬ 
chic disturbances described by the 
writer, all the symptoms became con¬ 
siderably worse while the patient 
took pituitary extract, whereas the 
administration of a thyroid prepara¬ 
tion instead coincided with disappear¬ 
ance of the headachq, dizziness, and 
vomiting, and an improvement in the 
mental state. Renewed pituitary 
treatment caused all these symptoms 
to reappear, after which they yielded 
again to thyroid treatment. Salomon 
(Presse med., Dec. 13, 1913). 

Favorsky, using Poehrs opohypo- 
physine, noted distinct improvement 
in the subjective, and even the objec¬ 
tive, symptoms. The latter observer 
was able to continue the administra¬ 
tion of hypophysine in daily doses of 
0.05 to 0.06 Gm. to 1 grain) for 
fifteen months, without untoward 
effects. For our part, we have utilized 
the various animal preparations in a 
systematic manner and for extended 
periods, and have been led to the con¬ 
clusion that they are entirely in¬ 
effective. 

Beclere, Jaugeas and others have ob¬ 
tained amelioration of the pressure 
symptoms, including ocular phenom¬ 
ena by means of X-rays. It has also 
given good results after operative de¬ 
compression. 

The headache of acromegaly which 


may become very severe is palliated 
by the use of antipyrine, acetanilide, 
or acetylsalicylic acid. Sajous ob¬ 
tained contraction of all soft tissues 
by means of quinine hydrobromide 5 
grains (0.3 Gm.) with ergotin 1 grain 
(0.065 Gm.) t. i. d. and massage of 
thickened areas. 

Operative Treatment. — Surgeons 
emboldened by the increasing safety at¬ 
tending their operations, were not afraid 
to attempt the removal of the hy¬ 
pophysis. The anatomical situation of 
the gland seemed to m^ke the access 
to it well-nigh impossible. Never¬ 
theless, encouraged by the results 
obtained by physiologists, and hav¬ 
ing gained additional information 
through researches on the cadaver, 
the operators ascertained the avenues 
of entrance which would permit of 
their reaching the pituitary gland, 
and on November 16, 1907, Schlosser 
performed the operation of removing 
a tumor of the hypophysis from a living 
person. 

In theory, the hypophysis may be 
reached, according to Toupet, either by 
an intracranial or by an extracranial 
route. Those who favor the intracranial 
method advance as their chief argument 
the less danger of infection to which the 
patient is subjected, and propose either 
the frontal route (Krause, Kiliani) or 
the temporal route, already employed 
in their experiments by Caselli and 
Horsley. 

At the present writing (1918) the 
chief indication for operation is to re¬ 
lieve the pressure of the growth on 
surrounding important structures. 
Hence the term “decompression oper- 
ation’’ now extensively used. The 
tumor may be partially removed, or 
space in neighboring structures of 
little importance may be provided to 


ACROMEGALY (LAUNOIS AND CESBRON). 


307 


accommodate it if it cannot be re¬ 
moved. 

Special precautions are necessary 
when an operation is to be resorted to. 


especially thin in most instances. 
The tumor may itself alter greatly 
the shape of the sella and erode its 
walls sufficiently to penetrate it. A 



The pituitary, marked with a white cross, can be seen in its 
dorsal sheath. (li. Proust .) 


Both the Sphenoidal cells and the radiograph will furnish an outline of 

sella turcica vary greatly in size, the sella and afford a pretty correct 

depth, shape and thickness, the pos- estimate of the size and location of 

terior of the sphenoidal sinus being the growth. 











308 


ACROMEGALY (LAUNOIS AND CESBRON). 


A trained brain surgeon should be 
entrusted with the operation. Some 
prefer general anesthesia, others local 
anesthesia, a strong solution of cocain 
(20 per cent, solution) with adrenalin 
being used. 

In the United States two methods 
have proven fairly satisfactory. The 
Hirsch-Cushing submucous nasal 
method and the fronto-orbital method 
of Frazier. 

In the Hirsch-Cushing operation 
intra-tracheal anesthesia is employed. 
The upper lip is raised and a short 
incision made down to the anterior 
nasal spine of the superior maxilla, 
the soft parts scraped back until the 
cartilaginous septum is exposed, and 
the septal membrane then separated 
on each side as in submucous resec¬ 
tion. Upon insertion of a retractor 
1.8 cm. in breadth and 6 cm. in length, 
to separate the freed layers of mucous 
membrane, most of the vomer, the 
lower edge of the median plate of the 
ethmoid, and a small strip of the car¬ 
tilage are removed. A series of dilat¬ 
ing plugs, .up to a diameter of 1.8 cm. 
are now introduced to flatten the tur¬ 
binates slightly, the retractors then 
withdrawn, and a self-holding, bivalve 
speculum, with blades about 7 cm. 
long, inserted. The sphenoidal sinuses 
having been identified, their anterior 
and lower walls are chipped away 
with long-handled nasal rongeurs, the 
lining mucosa of the sphenoid cells re¬ 
moved, and the floor of the pituitary 
fossa, forming a protrusion into the 
cells, also chipped away. With a 
knife-hook a crossed incision is finally 
made in the dura covering the pitui¬ 
tary or growth, and the latter appro¬ 
priately dealt with. Termination of 
the operation consists merely in 
checking bleeding completely, with¬ 


drawing the speculum, and closing the 
lip incision by means of two or three 
catgut sutures, without drainage. 
The 2 layers of septal membrane, as a 
rule untorn, fall together, and the 
entire procedure is thus conducted 
without actually entering the nasal 
passages. 

The mode of procedure as regards 
the exposed pituitary area depends 
upon the lesion discovered. A mere 
growth under the sella proper arising 
perhaps from a pituitary rest may be 
removed. If, as is usually the case, 
the tumor is located higher up and 
large, even composed of pituitary tis¬ 
sue, the sellar decompression des¬ 
cribed may suffice to restore vision by 
relieving the pressure on the optic 
nerves. A later operation may be¬ 
come necessary, particularly if the 
nature of the growth is in doubt. 
When a greatly enlarged sella is filled 
with a large pituitary growth, the por¬ 
tion of the latter resting on the sella 
may be scooped out with but little 
bleeding. An intrapituitary cyst 
should be evacuated. 

Out of 95 operated cases the writer 
had in 37 subtemporal decompression 
2 fatalities, 8 subtemporal explora¬ 
tions without mortality, 6 subfrontal 
explorations with 1 death, 16 tran- 
sphenoidal decompressions with 3 
deaths, and 58 transphenoidal extir¬ 
pations, with 4 deaths. The total 
operative mortality was thus 8 per 
cent, and the case mortality, 10.5 per 
cent. In the last 33 transphenoidal 
operations there was but 1 death,—a 
mortality of only 3 per cent. C. 
Cushing (Jour. Amer. Med. Assoc., 
Oct. 31, 1914). 

In the Hirsch method the middle 
turbinates are usually removed as a 
preliminary measure some days be¬ 
fore the main operation. At the lat¬ 
ter, performed under local anesthesia, 


ACROMEGALY (LAUNOIS AND CESBRON). 


309 


the initial incision is made through 
the mucous membrane over the nasal 
septum, on one or the other side. 
Special precautions are taken to in¬ 
sure asepsis. The exposure of the 
pituitary is transphenoidal, as in 
Cushing’s procedure. Of 26 cases 
thus dealt with, 4 succumbed as a re¬ 
sult of the operation. 

The writer employs Hirsch’s 
method with a slight modification; 
he detaches one of the mucous mem¬ 
branes in order to render the spheno- 
hypophyseal cavity accessible by a 
nasal fossa. This he deems very im¬ 
portant when treating neoplasms 
originating from the sella turcica 
which become extrasellar, and pene¬ 
trate into the cerebral cavity and 
consequently incapable of total extir¬ 
pation. The modification is also use¬ 
ful where intrasellar growths have a 
tendency to recur. By insuring easy 
access to the sphenoidal cavities and 
keeping in contact with the sella tur¬ 
cica, it facilitates the subsequent use 
of radiotherapy. His 7 cases promptly 
healed by first intention. E. V. 
Segura (Rev. Asoc. med. Argent., 
xxvii, 984, 1917). 

Although recognizing the value of 
Cushing’s method and its excellent 
results, the writer contends that it 
entails danger of meningitis owing to 
the fact that the sphenoidal ostia 
open into the nose. He deems 
Frazier’s fronto-orbital method (see 
below) more suitable than the sub¬ 
mucous procedure in most cases. 
While Frazier had no mortality in 4 
cases, Cushing’s series of 16 cases 
had 1 death. Cope (Lancet, Mar. 18, 
1916). 

In Frazier’s operation, or fronto- 
orbital method, the relation of the 
frontal sinuses to the supra-orbital 
margin is first ascertained by transil¬ 
lumination. An osteoplastic flap is 
then formed in the frontal region, the 
incision starting at the external angu¬ 
lar process, coursing through the eye¬ 


brow line to the root of the nose, as¬ 
cending to within the hair line, turn¬ 
ing outward again, and returning to 
the temporal region on a level with 
the beginning of the incision. In 
forming the bone flap the outer por¬ 
tion of the supra-orbital ridge is re¬ 
moved as a wedge-shaped piece. The 
periosteum is then freed from the 
roof of the orbit, the roof removed 
with rongeurs back to the optic fora¬ 
men, and if necessary, a small opening 
made in the dura to permit cerebro¬ 
spinal fluid to escape and thus allow 
greater displacement of the frontal 
lobe. The orbital contents are drawn 
downward and outward, with flat re¬ 
tractors, the frontal lobe with its 
dural covering raised, and the dura 
then incised horizontally about a 
centimeter above the base of the skull 
sufficiently to admit a retractor and 
expose the contents of the sella. 

The advantages claimed for the 
fronto-orbital route are, that it pro¬ 
vides an aseptic route, that it allows 
each step of the operation to be per¬ 
formed under direct vision, and that 
since the primary enlargement of 
pituitary tumors is towards the brain, 
the organ is thus an easier object for 
attack than it is from the infrasellar 
exposure. 

For the removal of cysts Kanavel’s 
operation is advantageous. The in¬ 
cision is made in the crease of the skin 
immediately under the nares and alse 
of the nose. The nasal spine is then 
cut and the mucous membrane care¬ 
fully raised from the floor of the nose 
and off of the septum, back to the 
sphenoid bone and off from the front 
of the latter. The pituitary is then 
exposed through the sphenoid as in 
Cushing’s operation. In the first of 
Kanavel’s cases the cyst found was 


310 


ACROMEGALY (LAUNOTS AND CESBRON). 


thoroughly curetted, with the result 
of bringing the existing typical Froe- 
lich syndrome to a standstill and re¬ 
lieving the marked signs of intra¬ 
cranial pressure. Dried pituitary 
gland was fed for over 3 years. Six 


ous titles such as epithelial tumors of 
the infundibulum, papilloma of the 
choroid plexus, cystic endothelioma 
of the pia, adenoma, adenosarcoma, 
dermoids, etc. The epithelial inclu¬ 
sions forming the starting-point of 
such tumors reach the pituitary from 



Relations of pituitary body, as exhibited by removal of the bony floor of 
anterior cerebral fossa. {Proust ) 


years after the operation the patient 
was still living and well. The second 
case succumbed to meningitis after 
the operation, while the third was op¬ 
erated upon on 3 successive occasions 
for pressure relief, with ultimate 
recovery. Three years after opera¬ 
tion there had been no recurrence of 
symptoms. 

These cysts actually arise through 
inclusion of buccal epithelium in the 
hypophyseal region, the remains of 
Rathke’s pouch, e.g., persisting near 
the infundibulum and later prolifer¬ 
ating to form cystic or adamantine 
tumors, hitherto reported under vari- 


the craniopharyngeal duct, which in 
the embryo forms a passage from 
pharynx to brain cavity traversing 
the sphenoid bone. Kanavel (Surg., 
Gynec. and Obstet, Jan., 1918). 

As previously stated. X-ray treat¬ 
ment is often resorted to advan¬ 
tageously by Cushing after operations, 
when the growth tends to enlarge 
rapidly or to recur. The exposures 
are made through the nares and over 
the temple on alternate days. 

Different measures should be adopted 
under different circumstances: (1) 

comparatively small tumors in the sella 
turcica covered with a tent of dura 














ACTINOMYCOSIS (LAPLACE). 


311 


mater can be removed completely by 
the nasal route; (2) growths growing 
endocranially, but filling the sella tur¬ 
cica, can be removed in part to relieve 
the pressure symptoms, though not the 
acromegaly; (3) endocranial growths, 
removal of which can only prove harm¬ 
ful. Hochenegg (Deut. Zeit. f. Chir., 
Bd. c, S. 317, 1909). 

Confirmation of Paulesco’s observa¬ 
tion that simple di’u'sion of the stalk 
of the pituitary is as fatal a procedure 
as removal of the latter organ also, 
and also of the view that the latter 
procedure in animals is invariably fol¬ 
lowed by death within a few days. 
This fatal result is evidently due to re¬ 
moval of anterior or epithelial lobe, 
since removal of the posterior or neural 
lobe is followed by no characteristic 
symptom. Cushing and Bedford (Johns 
Hopkins Hosp. Bull., April, 1909). 

P. E. Launois 

AND 

M. H. Cesbron, 
Paris. 

ACTINOMYCOSIS.—D E FI NI- 
TION. — A parasitic, infectious, and 
inoculable disease due to the develop¬ 
ment of the actinomyces, or ray fungus. 
First described in 1877 in cattle by Bol¬ 
linger and in man by James Israel; it 
can no longer be considered a rare dis¬ 
ease. From its frequent development 
in the lungs it has often been confused 
with tuberculosis. 

SYMPTOMS. —The symptoms vary 
according to the locality of the disease. 
The affection is chronic and exception¬ 
ally rapid. The granulation tissue is 
abundant and the mass resembles a 
tumor. Previous to suppuration it is 
quite firm, and, if progressing rapidly, 
is surrounded by diffuse edema. Pain 
and tenderness hardly ever exist. When 
suppuration occurs the mass increases 
rapidly in size. 

Actinomycosis may develop in almost 
any part of the body, but Poncet and 


Berard showed, after an investigation 
of 500 reported cases, that the sites of 
predilection were relatively as follows: 
Head and neck, 55 per cent.; thorax 
and lungs, 20 per cent.; abdomen, 20 
per cent.; other parts, 5 per cent. In 
France the face and neck were affected 
in 85 per cent, of the 66 cases reported. 

Actinomycosis should always be 
considered in the diagnosis in the 
case of any newly formed subacute 
or chronic swelling in the region of 
the mouth, face, neck, thorax, or right 
side of the abdomen. Pus from 
every abscess should be examined as 
a routine practice. In any subacute 
or chronic lesion, the discharge needs 
to be examined repeatedly. Peribuc¬ 
cal infections comprise the majority 
of the cases. Cope (Brit. Jour, of 
Surg., July, 1915). 

1. Cutaneous Surface.—Usually, a 
lesion of the skin is secondary to the 
evolution of an underlying actinomy¬ 
cotic tumor, which, by its growth, bursts 
through the skin. A sanguineous or 
purulent liquid, containing the charac¬ 
teristic grains, issues from the ulcera¬ 
tions so formed. The grains are small, 
opaque, yellowish-white, or yellowish 
masses about as large as a pinhead, 
which are composed of smaller grains, 
measuring about %o These smaller 

grains are formed by a central mass, of 
interwoven or straight fibers, whence ex¬ 
tend toward the periphery spoke-like 
prolongations, with club-like termina¬ 
tions. Rarely the affection may develop 
primarily on the fingers, hand, nose, or 
face. It forms a small, round, ligneous 
mass, which may soften in a few weeks, 
burst through the skin, and give a gran- 
ulous and varied pus, containing actino¬ 
mycotic granulations. The border of the 
granulation is uneven, violet-hued, and 
undermined. Around the original mass 
there arise secondary masses; so that 
the entire lesion forms a violet-red, in- 


312 


ACTINOMYCOSIS (LAPLACE). 


(lurated patch, deeply adherent, and 
somewhat resembling scrofuloderma. 

In cutaneous actinomycosis the lym¬ 
phatic ganglia are usually not enlarged. 
Pain is, in some cases, intense; in other 
cases it is awakened only by pressure. 
The pathognomonic spots, which are 
more or less deep in color, according as 
the general color of the lesion is more 
or less pronounced. If the general color 
is pale,the spots are bluish red or violet; 
if the tint of the mass is deeper, the 
spots present a blackish or slate color. 
These spots vary in size from that of a 
pea to that of a pin’s head. They ap¬ 
pear to correspond to the points at 
which the wall of the abscess is thinnest, 
and it is here alone that fistulse form. 

In some instances, as in the case re¬ 
ported by Pringle and illustrated in the 
annexed colored plate, the lesions may 
assume the appearance of large sarco¬ 
matous-looking growths, ulcerating at 
various points, situated upon hard, 
brawny, and deeply undermined skin 
and from the ulcerative points of which 
pus exudes, mixed with characteristic 
yellow granules, actinomycosis. 

2. Alimentary Canal.— Teeth .—The 
fungus has been found in carious teeth 
(Israel), often side by side with lepto- 
thrix (Senn), or almost pure culture 
with no manifestation of disease except 
chronic periodontitis (Partsch). Cari¬ 
ous teeth have increasingly been shown 
to act as etiological factor of the 
affection. 

Tongue and Tonsils .—In man three 
cases of this affection have been found 
on the tongue, one of which was of pri¬ 
mary development; the other two are 
believed to have found origin in a ca¬ 
rious tooth. The tonsils may also be 
affected and be the seat of white projec¬ 
tions resembling masses of moss, which 
seemed to grow in the crypts. The 


pharyngeal wall also shows these white 
masses, as a rule. 

Lingual actinomycosis in cattle ap¬ 
pears as a nodular tumor, with prolon¬ 
gations into the parenchyma, of ligneous 
hardness. 

Jaws .—The lower jaw is the most 
frequently affected. At first the disease 
resembles periosteal sarcoma, until the 
loose tissues of the neck are reached, 
when it often rapidly extends downward 
along the subcutaneous connective tis¬ 
sues and intermuscular septa. Accord¬ 
ing to Poncet, an early sign of actino¬ 
mycosis in this location, in some cases, 
is a marked difficulty in opening the 
mouth, long before the presence of the 
disease can be determined microscopic¬ 
ally. 

The upper jaw is rarely primarily 
affected. It then tends to attack rapidly 
the adjacent parts, and even the base of 
the skull and brain. 

A primary actinomycosis infection 
of all salivary glands can take place. 
The disease in the early stage has a 
definite clinical as well as pathologic 
picture. In a relatively short time 
the writer observed 9 primary cases. 
Eight of these were very early cases 
of primary actinomycosis of the sali¬ 
vary glands. Altogether he reports 
31 cases, 7 of which originated from 
the submaxillary gland. The infec¬ 
tion entered positively by the duct 
route in some of the cases and prob¬ 
ably in the others also, the patient 
chewing a stem of grain bearing the 
actinomycotic organism. Three dif¬ 
ferent stages are observed: a diffuse 
inflammatory process, a localized 
abscess, and a spreading abscess 
within the gland, eventually forming 
new abscesses and finally breaking 
through with the formation of fis- 
tulse, either external or internal. G. 
Soderlund (Nord. med. Ark., xlvi. 
No. 4, 1914). 

3. Intestinal Canal.—The disease be¬ 
gins with a sharp, lancinating pain in 


Case of Actinomycosis Extensively Involving the Skin, {Pringle.^ 
Transactions of the Royal Medico-Chirurgical Society. 


1 ^ 








ACTINOMYCOSIS (LAPLACE). 


313 


the abdomen and follows the course of 
chronic peritonitis. Swejlings form¬ 
ing abscesses are found on the anterior 
abdominal wall, which sometimes 
communicate with the intestine. It 
may also start from the vermiform 
appendix. There have also been cases 
of primary actinomycosis of the colon 
with metastatic deposits in the liver. 

Actinomycosis of the intestines is 
characterized by extensive induration 
due to a marked development of peri¬ 
toneal adhesions and to the exten¬ 
sion of the process to the abdominal 
wall and neighboring organs. As be¬ 
fore mentioned, the tendency to the 
formation of the fistulae is marked. 
Metastatic involvement of the liver 
is not unusual. G. S. Towne (Albany 
Med. Annals, June, 1917). 

An acute or chronic inflammation 
of the appendix may open the door 
for the entrance of the actinomycotic 
organism. In general, actinomycosis 
is practically never carried by the 
lymphatics and but rarely by the 
blood stream. The method of exten¬ 
sion is by continuity of tissue. Thus 
it is that general actinomycosis, un¬ 
like tuberculosis and blastomycosis, 
is extremely rare. Many of the ab¬ 
dominal organs may become in¬ 
volved, as extension of the process 
usually takes place through retro¬ 
peritoneal tissues, sometimes de¬ 
stroying muscles and even bones. 

The early diagnosis of actinomy¬ 
cosis is generally overlooked. A firm 
swelling, painless on pressure, oc¬ 
cupying either the right or left in¬ 
guinal regions, usually the right, is 
the sign most frequently found in 
intestinal actinomycosis. J. W. Keefe 
(N. Y. Med. Jour., Nov. 30, 1918). 

There are 3 types of actinomycotic 
infection of the appendicocecal re¬ 
gion, the first with a painless tumor 
in the right iliac fossa with ultimate 
formation of abscesses and fistula; 
the second simulating acute appendi¬ 
citis, with the appendix usually 
found gangrenous at its base; and 
the third with an infected patch in 


the cecum, which perforates, giving 
rise to secondary generalized periton¬ 
itis. The writer’s case was of the 
third type, in a woman, 32 years of 
age, with recurrent pain in the right 
iliac fossa for 2 years. Much pus 
was found in the pelvis and the cecum 
showed a thickened patch with cen¬ 
tral perforation. The normal appen¬ 
dix was removed, the cecal patch 
with its subsequent invagination was 
scraped, and the peritoneal cavity ir¬ 
rigated with saline solution by means 
of Carrel tubes, removed on the third 
day. Under potassium iodide, 50 
grains (3.3 Gm.), 3 times a day, the 
wound healed, and the patient recov¬ 
ered. E. G. Slesinger (Lancet, June 
5, 1920). 

4. Genitourinary Tract.—The uterus 
may also become invaded by the disease, 
the first manifestation being the dis¬ 
charge of a turbid, fetid fluid contain¬ 
ing the characteristic shreds and masses. 

The gross macroscopic and micro¬ 
scopic picture resembles that of tu¬ 
berculosis in many cases. Bollinger’s 
desideratum for the diagnosis of 
actinomycosis, namely, that corpora 
flava must be present, is untenable 
at the present time. Repeated bac¬ 
teriological examinations, and some¬ 
times long and tedious ones, of the 
same specimens must be made to 
insure a correct interpretation of sus¬ 
picious pathological material. Inocu¬ 
lation with pure cultures into the ani¬ 
mal is not attended with success. 
Only the injection of pus with actino¬ 
mycosis, or the ingestion of material 
upon which actinomycosis is grown, 
will prove successful in the produc¬ 
tion of actinomycosis in the animal. 
Actinomycosis does not travel by the 
lymphatics, and probably not by the 
blood route. The prognosis is favor¬ 
able in circumscribed cases, which is 
most likely the condition in which we 
find the uterine appendages. 

The treatment consists in radical 
extirpation and free drainage, the 
application of tribromphenolbismuth, 
or irrigation of the fistula with cop¬ 
per sulphate. The internal adminis- 


314 


ACTINOMYCOSIS (LAPLACE). 


tration of large doses of potassium 
iodide up to 75 grains a day, which 
exerts a positive healing eflfect. Carl 
Wagner (Surg., Gynec. and Obstet., 
Feb, 1910). 

5. Respiratory Tract.—In bronchitic 
actinomycosis the affection is less severe 
in winter than in summer, which is the 
contrary of what is observed in ordi¬ 
nary bronchitis. It can be classified in 
three groups: (1) lesions of chronic 
bronchitis; (2) miliary actinomycosis, 
and (3) cases with bronchopneumonia 
and abscesses. The lower lobe is at¬ 
tacked more frequently than the upper; 
the opposite is the case in tuberculosis. 
Actinomycosis of the lungs is found in 
20 to 30 per cent, of all cases of actino¬ 
mycosis. It probably originates in the 
mouth, and usually takes the form of 
bronchitis or bronchopneumonia. 

In a personal case of actinomycosis 
the patient seemed to have merely 
pneumonia except fo** a tender point 
on one rib and this swelled a little. 
The surgeon was rather skeptical 
when called on to open this small 
tumor, but this revealed typical 
actinomycosis. Hamburger (Uges- 
krift f. Laeger, Apr. 25, 1918). 

6. Brain.—Flere, tumor-like symp¬ 
toms exist during life, with headache, 
paralysis of the abducens, congestion of 
the optic papilla, and attacks of uncon¬ 
sciousness. In a case reported by Ran- 
son the autopsy indicated the probable 
mode of infection of the orbit and brain. 
A sinus was found leading from the 
orbit to the gum of the upper jaw; the 
ray fungus had probably lodged in or 
near a tooth, as it has so often been 
found to do. The fungus was probably 
carried into the system on an ear of 
corn chewed at harvesttime. Having 
reached the orbit, it crept along its outer 
wall and in the wall of the right cavern 
ous sinus to the base of the brain, ulti¬ 
mately setting up meningitis and small 


abscesses, and burrowing through the 
pituitary body and sella turcica to the 
cavernous sinus of the left side. 

The orbit is very seldom the seat 
of actinomycosis. A case is reported 
from von Brun’s clinic, and 9 cases 
are cited in detail from the literature. 
The author’s case was the first to be 
operated upon by temporary resec¬ 
tion of the upper part of the cheek¬ 
bone, a procedure which is consid¬ 
ered superior to Kronlein’s resection 
of the lateral portion of the orbit. 
The chief symptoms were exophthal¬ 
mos and failure of vision in the af¬ 
fected eye. There was also lack of 
mobility of thp eyeball. These symp¬ 
toms are, however, not pathognomo¬ 
nic of actinomycosis, it being essential 
to an exact diagnosis that the ray 
fungus be found in the pus. As soon 
as a diagnosis is made, or there is a 
well-grounded suspicion of this dis¬ 
ease, steps should be taken to radi¬ 
cally remove the focus of infection. 
Muller (Beitr%e z. klin. Chir., Bd. 
68, H. 1, 1910). 

DIAGNOSIS.—When the process is 
very rapid, actinomycosis may stimulate 
acute phlegmonous inflammation and os¬ 
teomyelitis, or, when widespread, syph¬ 
ilis. 

Sarcoma.—This form of neoplasm 
does not suppurate or break down so 
early. 

In the jaws it is to be differentiated 
from dental affections: epulis. 

Tuberculosis.—In this disease the 
lymphatic glands are infected, and the 
apices are usually the first involved. 

In actinomycosis of the lungs the 
causative organism may be found in 
the sputum and in the discharges 
from fistulse in the chest wall. In 
sputum the parasite is distinguished 
from the common leptothrix of the 
mouth by the fact that the filaments 
of the latter are larger, straighten, and 
thicker, do not branch, and are fre¬ 
quently adherent to epithelial cells. 


ACTINOMYCOSIS (LAPLACE). 


315 


Carcinoma.—The skin or mucous 
membrane involved is in close connec¬ 
tion with the tumor; in actinomycosis 
the skin will be found broken on micro¬ 
scopical examination. 

Syphilis.—gumma will, in two or 
three weeks, be sensibly affected by 
large doses of potassium iodide, which 
does not act so rapidly in actinomycosis. 

Lupus.—The diagnosis depends, in 
this condition, upon microscopical ex¬ 
amination. 

The writer was able to differen¬ 
tiate actinomycosis by the seroreac- 
tion in 8 cases, the only negative 
reaction being in a case in which the 
cure had been complete for over four 
years. The specific reaction is both 
by agglutination and by fixation of 
complement by means of the spores 
of the sporotrichum, Actinomyces 
cultures cannot be used for the tests, 
but the generic reaction with sporo- 
thrix spores is constant and lively. 
It is specific for actinomycosis, sporo¬ 
trichosis, and thrush, but these can be 
readily distinguished. Widal (Bull, 
de I’Acad. de Med., May 10, 1910). 

ETIOLOGY.—Both men and ani¬ 
mals are probably infected from vege¬ 
tables or water (Israel), from eating 
ears of barley, or rye, when the fungus 
penetrates through-the wound or abra¬ 
sion thus provoked, or in many cases 
through carious teeth. Intestinal acti¬ 
nomycosis is due to taking contaminated 
food or water, when the fungus be¬ 
comes implanted upon an already dis¬ 
eased tissue, multiplies, and causes ac¬ 
tive proliferation of the submucous tis¬ 
sue. It may be transmitted by kissing, 
as in a case reported by Baracz. Farm¬ 
ers should be warned against the habit, 
so common among them, in chewing 
bits of straw, wheat, oat-chass, etc., the 
most prolific cause of the disease. Ac¬ 
tinomycosis is frequently met with in 
shoemakers. This is due to their habit 


of placing their needles in their mouths 
(Ullmann). 

The disease occurs not only in 
cattle, among which it gives rise to 
the condition known as “big jaw” or 
“lumpy jaw,” but is met with also in 
hogs. In a case reported by Guinard 
actinomycosis of the lower jaw was 
acquired by a toothbrush-maker from 
holding washed hogs’ bristles in the 
mouth before inserting them into the 
holes in the toothbrush handles. 

No one has satisfactorily demon¬ 
strated the parasite out of the lesions, 
and nothing definite is known con¬ 
cerning its habitat in the outer world 
(Towne). 

The disease occurs nearly three 
times as often in the male as in the 
female sex. 

In a study of a large series of cases, 
Erving found the youngest case re¬ 
ported to have been a child 6 years 
old; the oldest was a man of 70. 
Most cases were in middle life. 
Thirty six per cent, of the patients 
had much to do with live stock or 
grain. In 62 per cent, of the cases 
the disease lasted over six months. 

The disease is a combination of ab¬ 
scess formation and new growth of 
connective tissue. In most cases the 
disease has the character of a sub¬ 
acute or chronic suppurative process, 
but in some cases the new growth of 
connective tissue may be so marked 
a feature of the process that it may 
present the character of a tumor or 
neoplasm. G. S. Towne (Albany 
Med. Annals, June, 1917). 

Direct infection from the flesh or 
milk of affected animals, i.e., from tis¬ 
sues or products other than the part 
actually diseased, does not occur, ac¬ 
cording to evidence so far obtained. 

Only 6 cases of actinomycosis of 
the ovary are on record, and none 
of these are primary. Case of the 


316 


ACTINOMYCOSIS (LAPLACE). 


latter kind in a patient who had lived 
in London for 16 years, but in 1903 
and 1904 was brought into contact 
with hay, straw, and corn, the usual 
sources of actinomycosis, and it is 
noteworthy that the symptoms date 
from 1904. The streptothrix must 
have reached the ovary by way of the 
blood-stream. Taylor and Fisher 
(Lancet, Mar. 13, 1909). 

The writer has observed a number 
of cases in which latent actinomy¬ 
cosis was roused to active prolifera¬ 
tion by some intercurrent trauma. 
He has also found similar instances 
in the literature. There may be an 
interval of years between the trauma 
and the manifest actinomycotic proc¬ 
ess; in one case seventeen and in 
another ten years had elapsed, and 
intervals of five and ten years are by 
no means uncommon. Noesske (Med. 
Klinik, Mar. 27, 1910). 

PATHOLOGY. —The actinomyco¬ 
ses were formerly thought to be mold 
fungi (hyphomycetes), but Bostroem, 
in 1885, proved by cultivating them 
that they were a variety of cladothrix, 
belonging to the schizomycetes. 

At present the parasite is considered 
to belong to the streptothrix group, 
and the name Streptothrix actinomy- 
ces has been applied to it. 

The actinomyces fungus can be 
cultivated in ordinary nutrient broth 
to which a few drops of fresh human 
blood have been added. It is advis¬ 
able to sow the material in two 
broths, one of which is covered by 
a layer of oil 1 cm. deep. After in¬ 
cubation for a few days, the fungus 
appears at the foot of the tube in 
small white puffballs. From such a 
growth a vaccine can be prepared. 
In 2 cases in v/hich a vaccine of the 
homologous organism was employed 
improvement resulted. Gordon (Brit. 
Med. Jour., Mar. 27, 1920). 

The mass is m.ade up of granulation 
tissue, which, except for the presence 
of the ray fungus, would be mistaken 
for a round-celled sarcoma. Epithe¬ 


lioid elements and giant cells are also 
seen. In the granular mass, or in the 
pus coming from a case of actinomy¬ 
cosis, the fungus itself appears under 
the form of small, yellow, brown, or 
even green masses, about a pinhead in 
size, which, on microscopical examina¬ 
tion, are found to be composed of a 
central interwoven mass of threads, 
from which radiate club-shape-ended 
rays; in some specimens certain rays 
project far beyond the others. In man 
the clubbed bodies are frequently ab¬ 
sent (Senn). The histological lesions 
are alike in the actinomycotic nodule 
and in the tuberculous follicle; only 
the foreign body differs. Water or a 
weak solution of sodium chloride 
causes the rays to swell enormously 
and lose their shape; ether and chloro¬ 
form seem to have no action. 

At a certain stage there are in every 
colony three elements, viz.:— 

1. Club-shaped formations. 

2. A centrally placed network of 
fungus filaments of varying shape and 
size. 

3. Fine coccus-like bodies (spores), 
which originate from the fungus fila¬ 
ments, and grow into long rods and 
branching twigs. 

Two types, the typical and atypical, 
should be recognized, according to 
Berestneflf. Typical actinomycosis is 
the disease in which occur the charac¬ 
teristic mycelial masses, having club- 
shaped radiations. Atypical actino¬ 
mycosis includes such diseases as Noc- ' 
ard s fargin de boeuf, and infections 
which clinically and anatomically re¬ 
semble actinomycosis, and are caused 
by mycelial organisms which corres¬ 
pond quite closely to the cultural 
peculiarities of the streptothrix ac¬ 
tinomyces, but fail to form the char¬ 
acteristic grains in the tissues and pus. 


ACTINOMYCOSIS (LAPLACE). 


317 


Case of strcptothricosis, a disease of 
man or animal due to one of the 
various forms of streptothrix. The 
manifestations of the disease probably 
differ in accordance with the forms of 
causative organism. If organisms of 
thread form are present the surgeon 
can be reasonably sure of the diagnosis. 
If the threads are branched he can be 
certain of it. The ray fungus is sel¬ 
dom found in humans, and is not in¬ 
variably found in bovine streptothricosis. 
The appearance of the disease varies 
with the stage in which it is seen. A 
description of the surface appearance 
of an early stage would by no means 
fit a well-developed or an advanced 
case. The appearance is greatly changed 
by mixed infection with pyogenic bac¬ 
teria. A severe secondary pyogenic 
infection may obliterate all appearances 
suggestive of streptothricosis, and in 
such a case it may be impossible to 
demonstrate the streptothrix. Certain 
persistent abscesses, particularly ab¬ 
scesses connected with the alimentary 
tract, are due to streptothrix infection 
and secondary infection with pyogenic 
bacteria. J. Chalmers Da Costa (An¬ 
nals of Surg., July, 1911). 

Staining.—The following stains have 
been used:— 

Wedl’s orseille (Weigert). 

Eosin (Marchand). 

Cochineal—red (Dunker and Mag- 
nussen). 

Hematoxylin alum (Moosbrugger). 

Gram’s method—section staining 
(Partsch). 

Safranin in aniline oil, followed by 
K. I. (Babes). 

Solution of orcein in acetic acid (Is¬ 
rael). 

Picrocarmin—fungus, yellow; other 
parts, red (Baranski). 

The actinomyces in a section are best 
shown by Gram’s method, first with 
methyl violet, then with Bismarck 
brown (Tillmann). 

Cultivation.—It is quite difficult to 
cultivate in coagulated blood-serum (O. 


Israel), coagulated blood-serum and 
agar-agar (Bostrom), and coagulated 
egg-albumin and agar-agar (Wolff and 
J. Israel). 

INOCULATION.— It has been suc¬ 
cessfully carried out by James Israel and 
Ponfick, from tissue and from pure cul¬ 
tures. 

Opinions differ as to its power of 
producing pus, a secondary infection by 
the pus-germs being thought the true 
cause of the pus sometimes found with 



a, Ray-funffus or masses, showing central myce¬ 
lium of actinomycosis, b. White blood-corpuscles, 
showing their relative size. (Poncet and Bi'rard.) 


actinomycosis. Dissemination by the 
lymphatic system never occurs. Glan¬ 
dular enlargement indicates secondary 
infection. 

1. Cutaneous Surface.—Around the 
primary lesion are small secondary le¬ 
sions. Two forms are described: (a) 
The anthracoid, which pursues a rapid 
course, with fever, and sometimes sep¬ 
ticemic in character. It is characterized 
by flat tumefaction, with multitudes of 
small openings with yellow granula¬ 
tions, from which thick pus exudes. 
{h) The ulcerofungous, which pursues 
a subacute course, with tendency to 
chronicity. In the face it tends to form 




318 


ACTINOMYCOSIS (LAPLACE). 


burrowing abscesses instead of recog¬ 
nizable tumors. 

2. Bronchial Tubes and Lungs.— 
Some observers believe that the peri¬ 
bronchial lymphatic vessels and glands 
disseminate the fungus or its spores in 
the lungs; when the fungus reaches the 
lung-tissue proper, granulation tissue is 
formed, which, through secondary in¬ 
fection, suppurates. Amyloid degenera¬ 
tion of other organs may occur, or 



There is widespread induration due 
to peritoneal adhesions, with exten¬ 
sion of the disease to the abdominal 
and nearby organs, including not in¬ 
frequently the liver. 

Actinomycotic growths in, the liver 
in man, according to Crookshank, have 
a characteristic naked-eye appearance, 
from their peculiar honeycombed struc¬ 
ture. The cases between the fibrous tra¬ 
beculae are full of caseous matter, in 




Rayfungrus (c, c.c), club-shaped bodies {d,d,d). and spores {a, a, a) found in the 
pus of actinomycosis. {Foncct and Bcrard .) 


metastasis of the disease, in case a pul¬ 
monary vein has been pierced. At times 
the pericardium or peritoneum becomes 
afifected (Striimpell). 

3. Alimentary Canal.—In the jaws 
the mass usually resembles a sarcoma, 
but, if incised before secondary infec¬ 
tion and suppuration has occurred, the 
reddish surface will be seen to be inter¬ 
mingled with yellowish spots, which are 
collections of actinomyces. 

In the intestines the fungus causes 
proliferation of the submucous tissue, 
and whitish patches. External fistulae 
are commonly found. 


which the more or less spheroidal 
masses of the fungus are imbedded. In 
museum specimens, which have been for 
some time preserved in spirit, the con¬ 
tents of the loculi may have fallen out, 
and the honeycombed appearance is then 
much more marked than in recent speci¬ 
mens. 

PROGNOSIS. —The prognosis is se¬ 
rious in proportion to the rapidity with 
which suppuration occurs. Actinomy¬ 
cosis of the upper jaw is more serious 
than actinomycosis of the lower jaw, as 
it has a greater tendency to invade the 
deep structures. Internal actinomycosis 




ACTINOMYCOSIS (LAPLACE). 


319 


is almost always fatal, owing to its in¬ 
accessibility. External actinomycosis 
may cause death from pyemia, septice¬ 
mia, and exhaustion. When so placed 
as to be easily removed and treated 
early the prognosis is favorable. A per¬ 
manent recovery usually follows a com¬ 
plete removal of the primary focus, as 
metastasis is rare (Senn). 

Actinomycosis has a pronounced tend¬ 
ency to spontaneous recovery except in 
internal organs (Schlange). 

From an analysis of 60 cases the fol¬ 
lowing conclusions are reached: When 
the disease involves the head and neck, 
except in a few cases when the base of 
the skull is invaded, the course is favor¬ 
able, recovery taking place in from three 
to nine months. It is exceptional for 
the fistula to persist or to form anew 
after the lapse of a year. Pulmonary 
actinomycosis may terminate in recov¬ 
ery. The prognosis of actinomycosis is 
the more favorable, as the anterior ab¬ 
dominal walls are involved and the 
posterior escape. Death usually results 
from amyloid degeneration and wasting. 
If actinomycosis presents pyemic mani¬ 
festations, a fatal termination is to be 
expected, as a number of vital organs 
are likely to be involved. Actinomy¬ 
cosis may pursue a chronic course, 
continuing thirteen years or longer, if 
functionally important organs be not 
involved, as when the process confines 
itself to the connective tissue about the 
spinal column. According to Bevan 
the prognosis is now much better than 
formerly, some cases recovering spon¬ 
taneously. If surgical treatment is 
not possible the prognosis is grave, but 
not always hopeless. 

TREATMENT.—1. General.—Po¬ 
tassium iodide was found useful in 
animals by Thomassen and Nocard. In 
man it should be thoroughly tried before 


surgical intervention is resorted to, es¬ 
pecially when the disease is so extensive 
as to prevent complete removal by surg¬ 
ery. The results obtained from iodide 
of potassium have been remarkable in 
some cases and negative in others. This 
divergence of views, according to Per- 
net, depends on the variation in the vir¬ 
ulence of the disease, in its evolution in 
different individuals, in the difference 
existing in the receptivity of the tissues, 
and on the influence of secondary in¬ 
fective processes. In recent and purely 
actinomycotic lesions the results may be 
excellent; in old-standing cases, and 
where the ray fungus is associated with 
streptococci, staphylococci, and the bac¬ 
terium coli commune, the drug treat¬ 
ment is less successful. 

According to Berard, in two-thirds 
of the cases of chronic actinomycosis of 
the face and neck the results of iodide 
treatment are nil. In three-fourths of 
the recent cases recovery has been ob¬ 
tained by it, combined with surgical 
treatment, and in one-fourth by iodide 
treatment alone. Potassium iodide can¬ 
not be regarded as specific in actinomy¬ 
cosis in man. If, at the end of some 
weeks, improvement is slight only, oper¬ 
ative interference should be carried out 
at once. 

The drugs which are the most suc¬ 
cessful in pulmonary actinomycosis, in 
the opinion of Sabrazes and Cabannes, 
are potassium iodide and eucalyptus. 
If there is any involvement of chest 
wall, surgical treatment should be 
undertaken. 

Incision alone will not cure the 
condition; there should also be given 
large doses of potassium iodide and 
a 10 per cent, solution of iodin may¬ 
be injected into the region of the 
lesion. Irrigation of the incisions 
and sinuses with diluted tincture of 
iodine is also of value. Both cases 


320 


ACTINOMYCOSIS (LAPLACE). 


were treated in this manner and re¬ 
covery was fairly prompt with little 
scarring. E. D. Telford (Brit. Med. 
Jour., Oct. 9, 1915). 

The injection of a 5 per cent, solu¬ 
tion of permanganate of potassium 
into the cysts has been of advantage. 

Six cases of actinomycosis appar¬ 
ently cured by injections of sodium 
cacodylate. On the first day a 10 per 
cent, watery solution (14 of a Pravaz 
syringeful) was injected intramus¬ 
cularly in the nates, increasing each 
day 14 syringeful until a full syringe¬ 
ful is given during one week, and 
then decreasing the quantity to the 
^/4 syringeful, and then commencing 
over. The local measures are con¬ 
fined to puncture or little incisions 
for abscesses. More extensive opera¬ 
tions are avoided. Foederl (Zen- 
tralbl. f. Chir., Bd. xxxv, p. 45, 1908). 

Many cases remain uncured no 
matter what is done. Such a severe 
case was treated by the writers with 
daily subcutaneous injections of 
sodium cacodylate, beginning with 
114 grains (0.1 Gm.), increasing to 15 
grains (1 Gm.) and then again de¬ 
creasing. The infiltrated mass was 
incised and into the surrounding 25 
per cent, iodipin was injected twice, 
the second injection being given 2 
weeks after the first. In a few 
months the wound was completely 
healed with hardly a scar. Bittner 
and Toman (Prag. med. Woch., Nu. 
27, 1913). 

Case of facial actinomycosis which 
was cured by the administration, at 
weekly intervals, of 4 doses of vac¬ 
cine, each containing 25 million frag¬ 
ments. Combined with this was the 
opening of the abscess and its curet¬ 
tage with dry gauze. C. W. Dean 
(Brit. Med. Jour., Jan. 20, 1917). 

The writers found methylene blue a 
specific for Actinomyces in the test 
tube, and used it in a clinical case, 
which cleared up under the treatment. 
Either Roentgen ray or radium is 
probably sufficient as a curative agent. 
Jensen and Schery (Jour. Amer. Med. 
Assoc., Nov. 27, 1920). 


2. Surgical.—Local measures which 
do not completely remove the infected 
tissues do harm, as they frequently 
give rise to secondary infection, rapid 
extension, and death. 

The best treatment of actinomy¬ 
cosis in the writer’s hands has con¬ 
sisted in the removal of the primary 
focus, and as much of the infected 
tissue as possible, with prolonged 
free drainage. Internally potassium 
iodide was given to the point of sat- 
, uration. Of late he has given copper 
sulphate internally and uses a solu¬ 
tion of it for the daily dressing of 
the wounds. Ramstad (Journal-Lan¬ 
cet, Dec. 15, 1916). 

Cauterization with solid silver nitrate 

in actinomycosis of skin and soft parts 
in which suppuration and fistulous 
tracts have occurred possesses a specific 
action on the actinomycosis (Kottnitz). 

3. Electrotechnical.—Two platinum 
needles, attached to the two poles of a 
constant-current battery, are to be in¬ 
serted into the tumor. Through the 
two needles a current of SO.milliam- 
peres is to be passed, while every min¬ 
ute some drops of a 10 per cent, iodide 
of potassium solution are to be injec¬ 
ted into the mass. The solution is de¬ 
composed into nascent iodine and po¬ 
tassium. This is repeated every eight 
days, each session lasting twenty min¬ 
utes, under an anesthetic (Gautier). 

Before suppuration all diseased tis¬ 
sues, glands, etc., should be removed 
and the parts, when possible, cauter¬ 
ized with the thermocautery. 

After suppuration the parts should 
be treated as if they were tuberculous, 
curetting and packing with iodoform 
gauze. 

Two cases in which actinomycosis 
was apparently cured by irradiation. 
The second patient had been oper¬ 
ated on repeatedly, undergoing about 
a year previously a partial resection 


ACTOL. ACUPUNCTURE. 


321 


of the upper jaw. The infiltrate dis¬ 
appeared completely under X-ray 
treatment alune and the hstula closed. 
R. Levy (Zentralbl. f. Chin, Jan. 25, 
1913). 

Case of Heyerdahl’s in which 4- eg. 
(% grain) of pure radium were ap¬ 
plied for 3 days to an actinomycosis 
beneath the right eye; there was 
complete cure in 2 months. H. E. 
Brunzel (Strahlentherap., vi, 1915). 

X-ray treatment especially com¬ 
bined with potassium iodide has been 
employed in the treatment of actino¬ 
mycosis but radium has been tried 
but little. The author formerly re¬ 
ported a case which was cured with 
radium after all other methods had 
failed. He has since had 5 other 
cases in which a prompt cure re¬ 
sulted. However, one case of actino¬ 
mycosis of the breast died of the dis¬ 
ease 4 months afterward. P. A. 
Heyerdahl (Trans. XI North. Surg. 
Congress, Goeteborg, July, 1916). 

A few cases were treated by the 
writer with the X-ray. In 1 case a 
beneficial action was noted; in an¬ 
other case, which is still under treat¬ 
ment, an extensive spreading of the 
disease resulted so that the X-ray 
treatment had to be discontinued. 
Numerous small abscesses developed 
which had to be incised. Rovsing 
(Trans. XI North. Surg. Congress, 
Goeteborg, July, 1916). 

Ernest Laplace, 

Philadelphia. 

ACTOL, or silver lactate, occurs in 
the form of a white powder, odorless and 
almost tasteless, which is soluble in 15 parts 
of water. Its color is changed when ex¬ 
posed to the light. Applied to the tissues, it 
causes coagulation of the proteids, in com¬ 
mon with the nitrate of silver. 

THERAPEUTICS. —Actol has marked 
antiseptic and disinfectant properties, ac¬ 
cording to the strength of solution used. In 
solutions of 1 in 500 to 200 it is used as an 
antiseptic for wounds. For infected wounds 
it may be employed as a disinfectant in 
stronger or even saturated solutions. But 
little discomfort is caused when the powdered 
silver lactate is applied to open surfaces. It 

1 - 


is claimed to have a deep-seated effect by 
penetration to the subjacent tissues, though 
known to be decomposed into other com¬ 
pounds when in contact with the superficial 
cells. Actol has also been used internally as 
an antiseptic. It has been found effective 
in diminishing intestinal putrefaction, at the 
same time causing a tendency to constipation. 
Some have even employed it internally and 
hypodermically for a general antiseptic action 
throughout the organism. Sixteen grains 
(1 Gm.) have been injected subcutaneously 
without serious results. S. 

ACUPUNCTURE. — This proced¬ 
ure is principally used for the relief of 
tension in edematous or congested tissues. 
It is especially useful in edema of the scro¬ 
tum, labia, and extremities when the tissues 
are sufficiently distended to threaten slough¬ 
ing. Acupuncture is also employed for the 
relief of pain in neuritis and muscular rheu¬ 
matism, especially in sciatica and lumbago; 
the benefit afforded, when such is obtained, 
is due mainly to reflex contraction of the 
blood-vessels of the area, thus reducing the 
congestion of the nervi nervorum and the 
sensory terminals to which the pain is due. 
In edema, the benefit is the direct result of 
the abstraction of considerable blood-serum 
imprisoned in the tissues. 

TECHNIQUE. — The instruments em¬ 
ployed are a very small narrow-bladed bis¬ 
toury and surgeons’ needles. The part should 
be carefully sterilized by first washing it with 
soap and water and then bathing it with alco¬ 
hol or a 1:2000 solution of mercury. The 
operator’s hands and instruments should like¬ 
wise be carefully sterilized. These pre¬ 
cautions are very important in view of the 
fact that edematous tissues are readily in¬ 
fected. If the patient is very sensitive to 
pain, the part may be anesthetized with ethyl 
chloride. 

For edematous tissues the small bistoury 
is the better instrument, one or two stabs, or, 
in large areas, many such, being practised, 
avoiding blood-vessels. A compress dipped 
in a warm 5 per cent, solution of boric acid 
is then applied to encourage escape of the 
serum. These must be frequently changed 
and the tissues kept very clean, as otherwise 
fetor soon appears. 

For muscular rheumatism, especially lum¬ 
bago, a number of round needles are thrust 
-21 


322 


ACUTE RHINITIS (SCARLETT). 


into the painful area from 1 to 2 inches, 
according to the fat overlying the part, and 
left in situ from five to ten minutes. The pain 
often ceases at once. Great care should be 
taken, on withdrawing the needles, not to 
break them, lest fragments remain in the 
tissues. In neuritis, sciatica, etc., the 
needles, several of them are thrust into the 
nerve 'sheath at intervals (not a difficult pro¬ 
cedure in large nerve ) and left in situ about 
five minutes. A fine hypodermic needle may 
be used, among the ordinary needles, with 
advantage, in the same way, and increase the 
efficiency of the treatment by being used to 
inject a little sterile water, which acts as 
an analgesic, or, if the pain be very severe, 
morphine. This treatment is efficacious in 
most instances where other measures have 
failed. S. 

ACUTE RHINITIS, OR 
ACUTE CORYZA.-DEFINI- 
TION. —An acute inflammatory condi¬ 
tion of the nasal mucous membrane, in 
which repeated attacks predispose to 
the extension of the inflammation to 
the neighboring cavities, as the pharynx; 
the larynx; the lower air passages; and 
to a lesser degree, to the accessory 
sinuses of the nose. 

A careless sneezer and the person 
who does not cover his mouth and 
nose when he coughs are breeders of 
acute coryza. The organisms which 
cause colds are so small that a mil¬ 
lion could rest on the head of a pin. 
When a person coughs or sneezes, a 
fine spray carrying with it untold 
numbers of these germs is spread 
into the surrounding atmosphere to a 
distance of several feet, and may be 
easily taken into the mouth and nose 
with the respired air. More direct 
contact, such as by kissing, the com¬ 
mon drinking cup, the common rol¬ 
ler towel, by pipes, toys, pencils, fin¬ 
gers, food and other things which 
have been contaminated by the 
mouth and nose secretions of a per¬ 
son having a cold also carry the dis¬ 
ease. Rucker (Pacific Med. Jour., 
Oct., 1917). 


Common colds of the ordinary type 
are infectious. It has been demon¬ 
strated experimentally that the virus 
of common colds occurs in the nasal 
secretions; and" that this virus is 
capable of passing through Berkefeld 
filters which are impermeable to ordi¬ 
nary bacteria. By the employment 
of special anaerobic methods the * 
virus of common colds has been cul¬ 
tivated in vitro by the writer, and 
has proved capable of repeated recul¬ 
tivation in subcultures. Experimen¬ 
tal inoculations have demonstrated 
that Berkefeld N filtrates of sub¬ 
cultures of the virus, in the second 
generation at least, are infective. 
Another minute micro-organism has 
been isolated from cultures made 
from filtered nasal secretions in com¬ 
mon colds. This micro-organism can 
be passed through Berkefeld N fil¬ 
ters, and has been recultivated from 
culture-filtrates. Although conclu¬ 
sive proof of its nature has not been 
adduced, the experiments suggest 
that the micro-organism described 
bears a definite relation to the true 
infective agent. Analysis of the re¬ 
sults of the writer’s experiments 
showed that of the ten men inocu¬ 
lated, seven developed clear cut and 
definite symptoms of acute coryza; 
two reacted questionably, while one 
remaining case exhibited no symp¬ 
toms. G. B. Foster (Jour, of Infect. 
Dis., Nov., 1917). 

SYMPTOMATOLOGY.— The ear¬ 
liest manifestation of an acute rhinitis 
is a sensation of dryness or irritation 
in the nose, which later becomes of an 
itching, tickling, or stinging character. 
Very often the attack is ushered in by a 
preliminary chill or “a creepy feeling.’* 
Sneezing is an early symptom, and is 
soon followed by a sensation of fullness 
in the nose, with subsequent obstruction 
to nasal breathing, and a dull throbbing 
headache over the site of the accessory 
cavities. A general feeling of illness, 
with aching in the limbs and back, fre¬ 
quently prevails. The sense of smell 


ACUTE RHINITIS (SCARLETT). 


323 


and taste are interfered with. Hearing 
is often markedly impaired, owing to 
the involvement of the mucous mem¬ 
brane at the orifice of the Eustachian 
tube, or the extension of the inflamma¬ 
tion through the tube into the middle 
ear. The voice is also altered and 
assumes a nasal intonation. There is a 
noticeable loss of resonance which 
characterizes the normal voice, and the 
sounds of m and n cannot be readily 
produced. The skin is dry and at times 
becomes hot from the presence of fever. 

Thirst and anorexia are also asso¬ 
ciated symptoms. The urine is scant 
and high colored. The existing consti¬ 
pation is usually responsible for the 
presence of the furred tongue. The 
eyelids are more or less swollen from 
the existing congestion, and a profuse 
lachrymation is not infrequently present 
from the extension of the inflammation 
through the nasolachrymal duct. The 
membrane of the nose is red, swollen, 
dry, and glazed, and is unduly sensitive. 
The nasal passages are practically oc¬ 
cluded by the swelling of the membrane 
and the erectile tissue of the turbinates 
to the capacity of the fossae, thereby 
greatly interfering with the normal 
physiological functions of the nose, as 
well as with that of deglutition. Owing 
to this existing obstruction, nursing 
infants at times manifest considerable 
difficulty in obtaining sufficient nourish¬ 
ment. 

The nasal discharge at first is scant, 
or it may be entirely absent, but it soon 
becomes copious, is clear, and, owing to 
the presence of an excessive amount of 
salines in its composition, it becomes 
very irritating to the skin of the upper 
lip and the nasal alae; in fact, the irri¬ 
tation not infrequently becomes so 
marked as to cause excoriation, or even 
cracking, of the bordering cutaneous 


surfaces. This condition, no doubt, is 
often very much aggravated by the 
frequent use of the handkerchief. 

As the disease progresses, the dis¬ 
charge becomes opaque, mucopurulent 
in character, thick and tenacious, and 
of a greenish-yellow color. A micro¬ 
scopic examination of the discharge 
shows a marked increase in the corpus¬ 
cular elements. 

No sharp line of demarcation exists 
between the second and the terminal 
stages of this disease. In three or four 
days the discharge gradually becomes 
thicker and scantier; the swelling of 
the membrane subsides; the constitu¬ 
tional manifestations gradually lessen 
and finally disappear; the special senses 
assume their normal activity, and in 
the course of a week or ten days all 
traces of the disease disappear. 

A significant feature of acute rhinitis 
is the possibility of the antrum of High- 
more, the frontal sinus, the ethmoid or 
the sphenoid cells, the Eustachian tube, 
or the middle ear becoming the seat of 
disease as the result of the extension of 
the inflammatory process. The naso¬ 
pharynx and the pharynx invariably 
become involved, partly through the 
extension of the inflammation by con¬ 
tinuity, and partly from the interference 
with the normal function of the nose. 

DIAGNOSIS. —The recognition of 
this condition, as a rule, is seldom 
fraught with many difficulties, and the 
diagnosis in most cases is usually made 
with considerable ease. It is important, 
however, to guard against the possibil¬ 
ity of a mistake by making careful in¬ 
quiry into the history of the attack, and 
also by making a cautious examination 
of the nasal cavities in order to distin¬ 
guish between a simple acute catarrh 
and a rhinitis as the result of mieasles, 
influenza, nasal diphtheria, hereditary 


324 


ACUTE RHINITIS (SCARLETT). 


syphilis, a foreign body, a tumor, and 
iodism. Cases of measles and in¬ 
fluenza will invariably show a higher 
temperature and greater constitutional 
disturbances, and in the former case 
the appearance of the rash will elimi¬ 
nate all doubt of the cause of the exist¬ 
ing nasal condition. Nasal diphtheria 
can be recognized by the existence of 
the characteristic grayish membrane in 
the anterior nares and in, the throat, 
associated with the usual constitutional 
symptoms. In the absence of the mem¬ 
brane, strong evidence of the condition 
continues to exist in the blood-tinged 
discharge, but a positive diagnosis can 
be obtained only by culture. The 
“snuffles” of hereditary syphilis is usu¬ 
ally found in very young children, with 
concomitant symptoms of this infec¬ 
tion, i.e., malnutrition, glandular en¬ 
largement, and in older children the 
characteristic Hutchinson’s teeth. A 
foreign body or a tumor can be detected 
on examination, and in cases of iodism 
a careful history will elicit the fact that 
a considerable quantity of the drug has 
been taken. 

Cases of acute rhinitis are occasion¬ 
ally encountered in which the causative 
agent is some chemical irritant. The 
diagnosis should not be difficult, as con¬ 
stitutional symptoms are rarely present; 
the duration of the attack is seldom, if 
ever, as long as the ordinary cases; and 
with the withdrawal of the cause the 
condition invariably subsides. 

The patient seldom seeks treatment 
for acute rhinitis much before the end 
of the first or the beginning of the 
second stage of the disease, and then 
gives a history of exposure, quickly 
followed by the nasal discomfort and 
the rapid development of the disease. 
This history, in conjunction with the 
more or less characteristic appearance 


of the conditions within the nasal 
chambers, will usually be sufficient 
evidence for a positive diagnosis. 

ETIOLOGY.—Predisposing Causes. 
—If careful observation were made in 
each case of acute rhinitis, it would, no 
doubt, frequently be seen that the at¬ 
tack occurs when the resisting powers 
of the body are below par. Under 
normal conditions a certain equilibrium 
is maintained for the production and 
the elimination of the waste products of 
the body; but, when, for some reason, 
the normal function of this apparatus is 
interfered with and there occurs a 
faulty elimination of the waste products 
or an overproduction of the same, body 
resistance is lowered and susceptibility 
to disease becomes more marked. This 
condition is undoubtedly often en¬ 
couraged by indiscreet action of the 
patient in regard to diet, causing digest¬ 
ive disturbances, torpid liver, and con¬ 
stipation, in which the consumption of 
food is out of proportion to the com¬ 
bustion, thus causing an autotoxemia, 
in which there is sometimes a marked 
evidence of uric acid. It is at this time 
that a coryza may be considered the 
nasal signal of systemic poisoning, for 
the blood will be found tainted with 
the products of faulty oxidation. Strong 
evidence of this condition will also be 
found in the urine, in which uric acid 
or mixed urates will be present. 

With such lowered resistance, one 
becomes easily affected by conditions 
such as prolonged confinement in an ill- 
ventilated room, extreme physical ex¬ 
haustion following overwork, or a se¬ 
vere mental strain A lowered nerv¬ 
ous tone; interference with the normal 
activity of the sudoriferous glands, 
and the absence of a natural covering 
for the head, as in baldness, are oft- 
times important predisposing factors. 


ACUTE RHINITIS (SCARLETT). 


325 


It is not uncommon to find in some 
patients showing a disposition to fre¬ 
quent colds some underlying patholog¬ 
ical condition within the nose, such as 
deviation of the septum, a stenosis, or a 
hypertrophic rhinitis, thus causing the 
current of air to be misdirected in such 
a way as to act as an irritant upon a 
more or less sensitive membrane, which 
is usually below par as the result of 
recurrent attacks. 

When frequent and persistent attacks 
occur in childhood, a careful examina¬ 
tion of the nasopharynx will sometimes 
show the causal agent to be the exist¬ 
ence of adenoids. Acute rhinitis is not in¬ 
frequently found in infants under three 
months and those who are suffering 
from malnutrition, as in rachitis. It is 
also thought by a noted pediatrist to be 
a complication of dentition. In suscep¬ 
tible children, the cause is often very 
trivial. A curious fact exists in that 
this affection is seldom found in old 
people. 

An hereditary tendency seems quite 
apparent in some cases, notably in chil¬ 
dren. In the majority of cases, how¬ 
ever, the direct cause can be traced to 
an improper mode of living. The child 
gets very little fresh air; is confined 
in a room which is improperly venti¬ 
lated, usually overheated; the windows 
of the bedroom are kept carefully 
closed at night for fear the child may 
catch cold; the clothing is very often 
ill excess of what is really needed, thus 
making it impossible for the individual 
to indulge in any active play with¬ 
out producing a profuse perspiration. 
Under these conditions the mucous 
membrane, especially of the nose and 
throat, soon becomes very sensitive and 
the child is a frequent sufferer of colds 

Evidence sometimes points to such 
chronic conditions as asthma, hay fever, 


rheumatism, tuberculosis, and syphilis 
as being factors in the production of 
acute rhinitis. Attacks in some persons 
can be attributed only to their idiosyn¬ 
crasy. Excessive sexual indulgence 
often shows a predisposition to pro¬ 
voke an attack, as do gastric and in¬ 
testinal diseases, and a neurotic tend¬ 
ency. Thermic and climatic condi¬ 
tions are sometimes to be considered. 

The writer inclines to the theory 
of the nasal mucosas in coryza as 
eliminators of substances resulting 
from faulty metabolism. Hagemann 
(Med. Rec., Feb., 14, 1914). 

The most potent general cause of 
colds in intestinal poisoning of a 
chronic nature, which leads to an al¬ 
teration of the vasomotor control, 
with the possible addition of a local 
cause to keep this active. Local 
causes may be divided into two 
classes, malformations of the nose, 
and chronic disease of the frontal 
sinuses; then there is the cold which 
is simply the manifestation of a gen¬ 
eral condition, such as grippe. The 
ordinary cold in the head is most 
often due to bacterial infection. J. 
G. Dwyer (N. Y. Med. Jour., May 11, 
1918). 

Exciting Causes.—Although certain 
depraved conditions of the body may be 
said to predispose to attacks of acute 
rhinitis, usually there are certain causes 
to which the attack may be definitely 
attributed. Exposure to cold and wet 
when the body is overheated; exposure 
to sudden or extreme changes in the 
atmosphere; the wetting of the feet 
when the system is debilitated from 
other diseases; or the chilling of the 
body from any cause, especially as the 
result of sitting in such a position as to 
allow a draft of air to strike the back 
of the neck or head. This seems to 
support the theory advanced by some 
that the impression of cold on certain 
parts of the body produces an inhibi- 


326 


ACUTE RHINITIS (SCARLETT). 


tory effect upon the vasomotor nerves 
controlling the blood supply of the 
nasal mucous membrane. 

The inhalation of certain irritating 
chemical fumes, such as those of iodine, 
chlorine, bromine and hydrochloric acid 
may result in a coryza. Sometimes the 
mere inhalation of irritating dust may 
produce an attack. Foreign bodies in 
the nose; or certain drugs, as ipecac 
and the iodides, may produce the same 
effect. Wagner is of the opinion that 
the inflammation is not infrequently 
the result of migration of bacteria from 
diseased tonsils. The examination of 
the nasal secretion often shoves the 
presence of a variety of micro-organ¬ 
isms, chief among which are the Micro¬ 
coccus catarrhalis, the Bacillus septus, 
the Bacillus FriedlUnder, and the Bacil¬ 
lus segmentosus of Cautley. 

The evidence seems indicative that 
the diphtheroids, particularly Bacillus 
segmentosus of Cautley, are concerned 
in the production of common colds. 
The Mierocoecus catarrhalis is much 
more general in its manifestation, and 
is, probably, also epidemic and pro¬ 
ductive of a rather more severe in¬ 
flammation. It seems likely the sym¬ 
biosis of these 2 organisms increases 
the virulence. The pneumobacillus 
of Friedlander is much more con¬ 
cerned in chronic conditions and is 
probably identical with the ozena 
bacillus. The pneumococcus of Fran- 
kel flourishes in any part of the upper 
respiratory tract and, when virulent, 
has been found in pure culture. Clin¬ 
ically, the segmentosus infection is 
most likely to be in the nose, seldom 
in the trachea, but may cause otitis 
media; Micrococcus catarrhalis is most 
apt of all to invade the larynx and 
trachea. W. Walter (Jour. Amer. 
Med. Assoc., Sept. 24, 1910). 

The writer reports having discov¬ 
ered in acute and chronic rhinitis a 
Gram-negative anaerobic organism 
(Bacillus rhinitis), which he regards 
as the exciting cause in at least some 


cases of coryza. Tunnicliffe (Jour. 
Amer. Med. Assoc., June 28, 1913). 

Experiments by the writer strongly 
suggested that the causative virus is 
ultramicroscopic and filterable, the 
clear filtrate obtained from passage 
of diluted coryzal secretions through 
a Berkefeld N filter, and even sub¬ 
cultures from this filtrate, causing 
rhinitis when dropped into the nos¬ 
trils of healthy subjects. G. B. Fos¬ 
ter, Jr. (Jour. Amer. Med. Assoc., 
Apr. 15, 1916). 

The literature shows no convincing 
evidence that any known organism is 
the primary cause of the common 
cold. Cultural studies fail to show in 
uncomplicated cases any variation in 
the flora which would enable one to 
select any organisms as the cause of 
colds. On the other hand, where 
clinical complications occurred, path¬ 
ogenic organisms were definitely as¬ 
sociated with them. The writer feels, 
therefore, that the primary cause of 
colds is probably an organism as yet 
unknown and certainly not one of the 
usual pathogens such as a strepto¬ 
coccus, pneumococcus, B. influcnace 
or staphylococcus. But the primary 
cold, whatever its final cause, alters 
the mucous membranes in such a way 
as to allow secondary bacterial in¬ 
vasion and consequent frequent de¬ 
velopment of local complications. The 
cultures clearly indicate that such 
complications are due to a variety of 
bacteria, such as pneumococcus, strep¬ 
tococcus, and staphylococcus. Bloom¬ 
field (Johns Hopkins Hosp. Bull., 
Apr., 1921). 

Whenever the disease is at all prev¬ 
alent, suspicion arises as to the pos¬ 
sibility of it being contagious or pro¬ 
duced by some infectious material in 
the air. It not infrequently ushers in 
an attack of bronchitis, laryngitis, or 
one of the acute infections, such as 
influenza, measles, typhoid fever, 
small-pox, or whooping-cough. 

PATHOLOGY.—An acute rhinitis 
is characterized by the same patholog¬ 
ical changes which take place in in- 


ACUTE RHINITIS (SCARLETT). 


327 


flammation of the mucous membrane 
elsewhere in the body, and may be con¬ 
sidered in three stages. 

Stage of Engorgement .—During this 
stage the mucous membrane is swollen 
and rather dark in color. The normal 
secretion at first is decreased, or even 
entirely arrested, and there occurs a 
proliferation of the epithelium. If the 
microscope could be used at this time, 
the blood-vessels would be seen to be 
markedly dilated and there would be 
more or less stasis of the blood-stream, 
permitting the adhesions of leucocytes 
to the blood-vessel walls. Their final 
penetration into the surrounding tissue 
is the beginning of the next stage. 

Stage of Exudation .—With the mi¬ 
gration of the leucocytes into the 
interstitial tissue, there is also a tran¬ 
sudation of altered blood-serum and a 
forcing out of erythrocytes. The dis¬ 
charge that follows is usually profuse; 
at first it is a mixture of mucous and 
serum, but this soon becomes of a 
mucopurulent type and finally purulent. 

Stage of Resolution .—This is char¬ 
acterized by the restoration of the 
normal function of the mucous glands, 
the secretion from which causes the dis¬ 
charge to become thicker and more 
opaque. The exudate within the mu¬ 
cosa is gradually absorbed, the lost 
epithelium in time is replaced by new 
cells, and the membrane is slowly re¬ 
duced to its normal size. 

PROGNOSIS. —This depends upon 
the severity of the attack and the extent 
to which the tissues are involved. The 
simple cases usually recover in the 
course of a few days to a week without 
any detrimental results. In some few 
cases, however, certain changes may 
take place in the tissues and increase 
their tendency to recurrent attacks. 
The prognosis becomes less favorable 


for an early recovery if the inflamma¬ 
tion should extend into any one of 
the accessory cavities of the nose and 
cause a suppurative process, or if there 
should occur an involvement of the 
middle ear by extension through the 
Eustachian tube. 

TREATMENT. —The treatment of 
acute rhinitis may be prophylactic, 
abortive, or curative, depending upon 
the cause of the attack. Persons who 
show a predisposition to recurrent at¬ 
tacks of coryza should guard the body 
against such conditions as favor their 
onset. The protective agencies of the 
body should be strengthened by regular 
and systematic exercise, especially in 
the open air, and should be of the 
nature of horseback riding, golf, ten¬ 
nis, or something as vigorous. Gray¬ 
son recommends, instead of medicine, 
good vigorous exercise several times 
a day, claiming that “the quickened 
capillary circulation and vigorous action 
of the sweat glands that accompany 
hard exercise are incomparably more 
beneficial than the merely passive leak¬ 
age that follows the use of diaphoretic 
drugs. If in addition to this an abun¬ 
dance of water is drunk and the supply 
of food is greatly reduced—almost 
stopped in fact—we may look for an 
amelioration of all the coryza symp¬ 
toms in a much shorter time than if our 
main reliance is vested in quinine, bella¬ 
donna, and opium combinations, that 
have had too long a vogue.” 

Proper discretion in diet should be 
practised, particularly by those who are 
victims of uric acid diathesis. Cold 
bathing, gradual at first, is an effi¬ 
cient stimulant to the relaxed vascular 
system. Proper selection of underwear 
and clothing, especially for outdoor 
service, should be made. 

If the patient is seen in the early 


328 


ACUTE RHINITIS (SCARLETT). 


stages, in the first few hours, the attack 
may be abbreviated, or the duration, at 
least lessened, if the proper treatment 
is immediately instituted. The patient 
should be given a mustard foot-bath, 
4 grains of quinine, 10 grains of 
Dover’s powder, a hot lemonade, and 
then put to bed with a liberal covering 
of bedclothes to encourage free per¬ 
spiration. This should be followed by 
active catharsis. The above treatment 
will usually necessitate the keeping of 
the patient in the house at least the 
following day. Aspirin is consider¬ 
ably used, often with benefit. 

Recent investigations lead to the be¬ 
lief that the isolation of the predomi¬ 
nating organism from the nasal secre¬ 
tion and the injection into the patient 
of a vaccine product from the same 
will frequently'abort an attack, and 
even establish a certain degree of im¬ 
munity for a short period of time. The 
earlier the injection, the more decided 
will be the result. A mixed bacterial 
vaccine is recommended by A. P. 
Hitchens. (See Bacterial \^accines, 
this volume.) 

By means of vaccine therapy, not only 
are we able to cut short an acute cold, 
but also to confer considerable im¬ 
munity against future attacks. By this 
method we can, further, often suc¬ 
cessfully treat *colds which have be¬ 
come chronic, e.g., chronic rhinitis, 
laryngitis, bronchitis, etc. 

In but few cases of common cold can 
a stock vaccine be employed with much 
hope of success; except in the case of 
the Bacillus septus we are not likely 
to do good by any vaccine other than 
that prepared from the patient’s own 
person. Having secured the specimen 
it is forwarded to an expert, and the 
vaccine can be prepared ready for use 
within forty-eight hours of its receipt. 
The best time for the injection is the 
evening, and the best spot the flank 
slightly above and internal to the an¬ 


terior superior spine. If the reaction 
is pronounced it may be necessary to 
keep the patient in bed for twenty-four 
hours. Campbell (Practitioner, Oct., 
1909). 

The immunity obtained lasts, on 
the average, from 4 to 6 months. In 
those subject to recurrent colds in 
winter an autogenous vaccine should 
be made from the first cold, to which 
may be added other stock “cold 
germs”: staphylococcus, 400 to 800 
million as the full dose; pneumococ¬ 
cus, M. catarrhalis, and M. tetragenus, 
of each 125 million; B, influenza, B. 
septus, and B. Friedlander, of each 
100 million; and streptococcus, 50 
million. Eight minims (0.5 c.c.) of 
the vaccine should contain the re¬ 
quired number of sterile germs. The 
vaccine is given in increasing dosage 
at weekly intervals until 4 to 6 doses 
have been administered. J. W. Fisher 
(Boston Med. and Surg. Jour., June 
5, 1913). 

The writer recommends the tak¬ 
ing of an X-ray plate of the sinuses 
in the headaches and neuralgia inci¬ 
dent to coryza, especially recurrent 
cases, and the use of autogenous vac¬ 
cines in treatment. His rule in vac¬ 
cine treatment is to begin with 3 
minims of vaccine followed by ^5 
minims at the end of 48 hours if 
there is no reaction, and then grad¬ 
ually to increase up to 10 minims, 
avoiding a reaction if possible. H. I. 
Fifield (Med. Rec., Mar. 10, 1917). 

Early convalescence and the return 
of the normal vigor will be augmented 
by the administration of tonics, strych¬ 
nine and quinine being two of the 
favorite remedies. After two or three 
days this treatment is not sufficiently 
efficacious and curative measures will 
have to be resorted to. 

The usual run of cases can be cured 
without confining the patient to the 
house, unless the weather is severe. In 
children, however, an attack which may 
be considered mild in an adult may be 
severe enough to confine the young 


ACUTE RHINITIS (SCARLETT). 


329 


patient to bed. On the first visit of a 
case of acute rhinitis, especially if early 
in the disease, the nasal discharge will 
be found thin and acid, and the mucous 
membrane markedly swollen. Reduc¬ 
tion in the size of the turbinal bodies 
can be obtained by the application of a 
1 per cent, solution of cocaine and a 
1:10,000 solution of the suprarenal 
extract. 

A solution of 2 per cent, cocaine and 
2^ per cent, antipyrin often acts to 
greater advantage in these cases, as 
the latter remedy prevents a violent 
reaction and frequently prolongs the 
contraction. 

In patients who are sufferers from 
gout, the cocaine will invariably fail to 
produce the desired reduction of the 
mucous membrane, but relief may be 
obtained by the free administration of 
colchicum. 

Cocaine should be used with the 
greatest care in infants, as they are 
particularly susceptible to its detri¬ 
mental effects. Weak solutions are 
permissible, however, when the symp¬ 
toms are severe and the infant is pre¬ 
vented from nursing. Powders contain¬ 
ing cocaine are often prescribed for 
adults; but it has caused cocaino- 
mania in so many cases that it should 
only be applied by the physician him¬ 
self with an insufflator to cause con¬ 
traction of the mucosa and the effect 
kept by means of a powder containing 
no cocaine which can be used as snuff. 

For use by the physician the follow¬ 
ing is efficient:— 

H Cocaine hydrochloride, 

Camphor .aa gr, j (0.065 Gm.). 

Pulverized sugar _3ij (8Gm.). 

Morphine hydro¬ 
chloride . gr. j (0.065 Gm.). 

Pulverized acacia. 

Bismuth subnitrate (4Gm.). 

Pulverized mallow. .. 3iss (6 Gm.). 


Enough to cover a dime to be in¬ 
sufflated in each nostril. 

Ointments may also be used con¬ 
veniently by the physician, by means 
of a flat probe. Lemoine recommends 
the following formula :— 

Cocaine hydrochloride. 


Salol .aa gr.% (0.021 Gm.). 

Menthol .. gr. ss (0.032 Gm.). 

Boric acid . 3ss (2Gm.). 

Petrolatum . 3j (30 Gm.). 


A piece the size of a large pea is 
applied with the probe to the swollen 
mucosa in each nostril. 

Insufflations may be made with :— 

IJ Calomel, 

Morphine hydro¬ 
chloride .aa gr, % (0.01 Gm.). 

Bismuth subnitrate .. 3iiss (10 Gm.), 

To sustain the effect Rudaux, 
Grosse and le Lorier recommend the 
instillation into each nostril, night and 
morning, of several drops of the fol¬ 
lowing solution:— 

Eucalyptol . gr. % (0.05 Gm.). 

Sterilized liquid 

vaselin . 5] (30c.c.). 

On the other hand, Weitlauer, of 
Innsbruck, commends the internal use 
of sodium salicylate, combined with 
Dover’s powder, which, it is said, will 
afford relief one hour after beginning 
treatment:— 

R Sodium salicylate .3j (30 Gm.). 

Dover’s powder . gr. xlv (3 Gm.). 

Spirit of peppermint... TT\,j (0.06 c.c,). 

To be divided into 20 powders, 1 of which 
is to be taken in a little water every three or 
four hours. 

Where obstinate coryza results 
from chemical irritation of the mu¬ 
cous membranes, the writer recom¬ 
mends the following solution:— 

B Sodii sulphidi... gr. Ixxx (5.3 Gm.). 

Glycerini . Siiss (75 Gm.). 

Aquce destillatce.. 5vj (25 Gm.). 

M. 















330 


ACUTE RHINITIS (SCARLETT). 


The solution is used as nasal douche 
twice a day, one teaspoonful of it 
being placed in a quart (liter) of nor¬ 
mal saline solution. G. Laurens 
(Jour, de med. de Paris, May 3, 1916). 

When the profuse watery discharge 
is very troublesome a powder con¬ 
sisting of 2 drams (8 Gm.) of bis¬ 
muth subnitrate, 1 dram (4 Gm.) of 
starch, >4 dram (2, Gm.) of gum 
arabic, with 2 drams (8 Gm.) of men¬ 
thol, or 10 grains (0.6 Gm.) of anti¬ 
pyrin may be snuffed up, and usually 
gives considerable relief. The writer 
has not been successful in the use of 
vaccines. If there is much headache 
or face pain an adrenalin spray of 1 
to 10,000 may be employed, but this 
is not usually necessary. Ordinarily 
after the alkaline spray the following 
spray is used: 

Acidi carboUci. tt^x (0.6 c.c.). 

Iodine, 

Kalii iodidi 

pip .aa gr. vj (0.4 Gm.). 

Aquce menth. 

dd .5ss (15.0 C.C.). 

Glycerini aquce 

q. s. ad .... Biij (90.0 c.c.). 

This is sprayed until it reaches the 
throat. After this an oil spray of the 
following composition is employed 
for about 10 minutes; 

01. cloves .... Tn,x (0.6 c.c.). 

Camphomen- 

thol .gr. xxiv (1.5 Gm.). 

01. pirn syl- 

vestris . ti^xx (1.2 c.c.). 

Liq. petrolati 

q. s. ad .... 5iij (90.0 c.c.). 

These measures are not expected 
to destroy all of the germs, but to 
lessen their virulence and to provide 
drainage. When the infection has 
reached the bronchi, expectorants 
alleviate symptoms and hasten re¬ 
covery. If the nose is treated in 
addition in the way outlined the pa¬ 
tient recovers in a little over half the 
time required when only internal 
medication is employed, and is able 
to attend to his business during the 
attack. T. F. Reilly (Amer. Jour. 
Med. Sci., May, 1917). 


Aromatic spirit of ammonia and 
sweet spirit of niter are recommended 
as excellent agents to “abort” a cold by 
Beverley Robinson. A couple of doses 
of acetylsalicylic acid are also helpful. 

One or two doses of 1 Gm. (15 
grains) each of acetylsalicylic acid, 
taken at the first indication of an on¬ 
coming cold in the head, will arrest it. 
The drug is especially effectual when 
the first tickling in the throat is felt 
toward evening, and the drug is taken 
then and again in the morning. This 
permits him to go about his surgical 
tasks after breakfast without any 
further symptoms of coryza. If acute 
rhinitis has developed or the coryza 
relapses, two or three further doses 
always cured it completely. The drug 
probably does not act on the bacteria, 
but it seems to enhance the resisting 
powers of the tissues. Sick (Miinch. 
med. Woch., July 16, 1912). 

The writer emphasizes the remark¬ 
able power of bicarbonate of soda in 
arresting a “common cold.” About 
y 2 teaspoonful in Ys of a tumbler of 
water, is repeated each half hour 
until 4 doses are taken. If the cold 
returns the same treatment causes it 
to cease permanently. L. Duncan 
Bulkley (Med. Record, Oct. 19, 1918). 

The administration of dionin, in 
grain (0.03 Gm.) doses, once or twice 
daily, has been recommended. 

At home the patient should be in¬ 
structed to use one of the well-known 
cleansing sprays, such as Dobell’s solu¬ 
tion, glycothymoline, or a solution 
made from Seiler’s tablets. 

A very useful and economical solu¬ 
tion is prepared by dissolving a tea¬ 
spoonful of salt in a pint of water— 
practically a normal salt solution—and 
using it freely in the nose. 

In using any cleansing solution, great 
care should be exercised in blowing the 
nose directly afterward, for when it is 
done too harshly some of the solution 
mixed with the nasal secretion may be 






ACUTE RHINITIS (SCARLETT). 


331 


blown into the middle ear through the 
Eustachian tube and set up an inflam¬ 
mation with the formation of an 
abscess. 

Following the cleansing, the inflamed 
mucous membrane may be protected by 
an oily solution composed of:— 

R Menthol, 

Camphor .aa gr. v (0.3 Gm.). 

Liq. albolene . fSij (60c.c.). 

This is to be sprayed in the nose, or 
several drops may be placed in each 
nostril, and snuflfed up, several times a 
day. If it is found impossible to drop 
the solution in the nose of a child, the 
application may have to be made by a 
brush. 

Another useful combination is:— 

R Menthol . gr. viiss (0.5 Gm.), 

Phenylsalicylate _Bss (2.0 Gm). 

Boric acid . 5ij (8.0 Gm.). 

M. fiat pulvis. 

Since the swelling of the mucous 
membranes renders the snufiflng up of 
the powder difficult, the patient will 
find it advantageous to use a piece of 
rubber tubing about 20 cm. long; the 
powder is placed in it at one end, and 
air blown through from the other end 
by the mouth. 

An excellent agent to keep the 
swelling of the mucosa down is the 
adrenalin ointment 1: 1000, a piece as 
large as a pea being applied in each 
nostril. 

During the early stage of the disease, 
when the nasal discharge is watery, one 
of the coryza tablets on the market can 
be used to good advantage to dry up the 
excessive secretion. This is particu¬ 
larly advantageous to those who are 
compelled to appear in public. A very 
satisfactory combination is the one 
devised and recommended by Dr. S. 
MacCuen Smith, which is made up as 
follows:— 


R Atropine sul¬ 
phate . gr. %oo (0.0001 Gm.). 

Strychnine sulphate. 

Arsenous acid.aa gr. (0.00027 Gm.). 
Morphine sul¬ 
phate . gr.i/ioo (0.0006Gm.). 

Quinine sulphate, gr. Ho (0.006 Gm.). 
Powd. camphor, gr. J4 (0.016 Gm.). 

By the time six of these are taken, at 
half-hour intervals, a dryness in the 
throat will be noticed. Only half of 
one should be given to a child of five 
years. Notwithstanding their known 
value among the laity, the indiscrimi¬ 
nate use of these tablets should not be 
encouraged, for their administration at 
a time when the nasal discharge has 
become inspissated renders the patient 
much more uncomfortable and the dis¬ 
charge more difficult of expulsion. 

In the third stage, when the mem¬ 
brane is relaxed and the epithelium is 
being shed more rapidly than it should, 
a spray composed of 20 to 60 minims 
of the distilled extract of hamamelis to 
the ounce of water may be used to good 
advantage. 

It seems almost needless to state that 
the diet in all cases of acute rhinitis 
should be restricted at the beginning of 
the attack, but as convalescence takes 
place it can gradually be increased and 
finally restored to its normal status. 

In those cases, and especially is this 
true in children, where there is a tend¬ 
ency to excoriation of the upper lip and 
the nostril, these exposed cutaneous 
surfaces should be protected from the 
irritating effect of the discharge by the 
application of vaselin or some simple 
ointment. 

Sodium salicylate causes a cold to 
abort if taken within twenty-four to 
thirty-six hours. Single dose of 7H 
grams (0.5 dram) often suffices. 
Taken later, it relieves symptoms and 
shortens attack. It is also valuable- 
in the chronic coryza of gouty sub- 








332 


ADDISON’S DISEASE (LANGLOIS). 


jects. Should be taken after eating 
and preferably in small doses, dis¬ 
solved in half a glassful of water, 
Courtade (Revue de theirap., Jan. 1, 
1910). 

The following spray recommended: 


Atropine . gr. ss (0.03 Gm.). 

Epinephrin ... gr. j (0.065 Gm.). 

Menthol .gr. xxiv (1.5) Gm.). 

Camphor . gr. xl (2.6 Gm.). 

Oil sweet al¬ 
monds .5 ij (60 C.C.). 

Liquid petrol¬ 
atum . 3 vj (180 c.c.—M. 


Thompson (Ohio State Med. Jour., 
. May 1, 1919). 

Rufus B. Scarlett, 

Philadelphia. 

ADDISON’S DISEASE.— In 1855, 
Addison pointed out in a historic mon¬ 
ograph (“On the Constitutional and 
Local Effects of Disease of the Supra¬ 
renal Capsules”) the relations between 
a disease known as “bronzed skin” or 
“bronzed cachexia” and lesions of the 
adrenal bodies. The interest excited 
by this work at once called forth nu¬ 
merous observations on the subject, 
and, while a certain number of the 
papers lent support to the idea of close 
relationship between the lesion of the 
adrenals and the syndrome which Addi¬ 
son described, in others a contrary 
opinion was expressed. In the year 
succeeding the publication of his first 
monograph, Addison brought out a 
paper in which he described a lesion of 
the semilunar ganglia unaccompanied 
by changes in the adrenals. 

We can thus state that it was Addi¬ 
son himself who originated the two 
theories which are still brought into 
requisition to explain the manifesta¬ 
tions of the bronzed disease: the 
theory of adrenal insufficiency and the 
nervous theory. Before discussing 
these hypotheses, a study of the dis¬ 
ease itself from the clinical aspect 
must first be made. 


SYMPTOMS. — When Trousseau 
proposed that the term “Addison’s dis¬ 
ease” be applied to the affection de¬ 
scribed by the Scotch physician under 
the name “bronzed skin,” he specifically 
designated “a singular cachexia espe¬ 
cially characterized by the bronzed 
hue assumed by the integument.” We 
therefore feel justified in including 
under the term Addison’s disease only 
those affections which are of the 
“bronzed disease” types, and not the 
aggregate of all the conditions resulting 
from functional disturbances of the ad¬ 
renals, i.e., “without melanodermia, no 
Addison’s disease.” The disease, even 
thus limited, still presents a number of 
clinical forms showing rather well- 
marked special characteristics. 

The writer has encountered a num¬ 
ber of cases in soldiers which would 
have been classed with the traumatic 
neuroses if it were not for the fact 
that the men presented certain symp¬ 
toms which we are accustomed to 
encounter with Addison’s disease, 
especially the pronounced bronzing. 
Analysis of the cases shows further 
a deficiency in the functioning of 
both parts of the suprarenals, but 
there are no manifestations of tuber¬ 
culosis, no status lymphaticus, etc. 
The course of the affection also is 
comparatively light and several of 
the men have materially improved, 
while the trend in all is upward. 
Yushtchenko (Russky Vrach, xvi, 
No. 5, 1917). 

Asthenia .—The patient is generally 
unable to state the exact period of on¬ 
set of the affection. In typical cases 
the pathological state is almost always 
one of adrenal tuberculosis which has 
invaded these organs secondarily, the 
patient is already in the wasting stage 
of tuberculosis, and it is difficult to 
recognize the new symptoms. Where 
there is primary adrenal tuberculosis, 
however, the symptomatology is more 







ADDISON’S DISEASE (LANGLOIS). 


333 


characteristic. Asthenia dominates the 
whole picture. The least physical effort 
is followed by extreme lassitude. At 
first the patient is still capable of ener¬ 
getic and rapid muscular activity, but 
he is not equal to sustained work; 
fatigue at once appears; later, as the 
process advances, lassitude becomes 
constant and the patient thinks of but 
one thing—avoiding the slightest exer¬ 
tion and remaining in bed in the dorsal 
decubitus. The mere ingestion of food 
requires an effort beyond the patient’s 
strength, and the administration of 
solid food becomes difficult. 

The earliest writers had been struck 
by the asthenia of Addison’s disease, 
and Jaccoud gave an excellent descrip¬ 
tion of it. But the exact conditions 
under which this fatigue occurs were 
learned through the labors of Langlois, 
Charrin, and Abelous, who explained it 
on the basis of a new conception of its 
pathogenesis. The study of muscular 
fatigue with the ergograph of Mosso 
permits of differentiating the resistance 
in an ordinary case of tuberculosis from 
that in one of Addisonian phthisis. 
The simple tuberculous subject will 
continue lifting the weight of the ergo¬ 
graph for two minutes, performing 
total work equal to 1150 grammeters; 
the Addisonian subject, after having 
lifted the weight just as energetically 
during the earlier contractions, becomes 
fatigued very soon and stops exhausted 
before the second minute, having per¬ 
formed work equal to only 750 gram- 
meters. If the weight to be lifted is 
placed at 2 kg., fatigue already ap¬ 
pears at the fifth contraction and the 
sum of work done is practically nil. 

Melanodermia, or bronzing, from 
which symptom the disease received its 
earliest appellation, often does not de¬ 
velop until after the asthenia. It ap¬ 


pears most frequently in the form of 
small, brownish macules scattered 
over the entire skin-surface, though 
most marked at certain points of 
election. The scrotum and labia 
majora, which are normally pig¬ 
mented, very frequently present a 
characteristic color. The mucous 
membranes are very often affected 
before the skin. The internal sur¬ 
faces of the cheeks, the labial com¬ 
missures, as well as the genital 
mucous membranes, should always 
be examined in asthenic subjects. 

The melanodermia may remain local¬ 
ized, and this is, indeed, more usually 
the case, but it may also become gen¬ 
eralized through confluence of the pri¬ 
mary patches and involve the whole of 
the integument, making the patient’s 
skin appear truly like that of a mulatto, 
though never like that of a full-blooded 
negro. Brault points out that the palms 
and soles are not involved, but these 
areas are imperfectly or not at all pig¬ 
mented in negroes, and even in the 
anthropoid apes the soles of the feet 
remain of a pink color. 

Case of Addison’s disease in a 
male, aged 31, in whom exposure to. 
the sun darkened the pigmentation, 
which involved the axillae, elbows, 
nipples, breast, the pubis, gums, lips, 
tongue. Of late the nails have be¬ 
come a dark brown. A. F. Chace 
(Post-Graduate, Feb., 1911). 

The writers observed a case of 
Addison’s disease in a boy, aged 12 
years. A general bronzing of the 
skin develope ’ -radually. It was espe¬ 
cially marked around the nipples, the 
umbilicus, and pudenda. There were 
a number of pigmented scars on the 
body but no buccal pigmentation. 
The boy developed synchronously 
loss of energy, drowsiness, a cough 
at night and nocturnal enuresis. The 
heart was small. An uncle and a 
brother are said to have had tuber- 


334 


ADDISON’S DISEASE (LANGLOIS). 


culosis. There were no signs of pul¬ 
monary or spinal tuberculosis and 
von Pirquet’s reaction was negative 
on two occasions. The skiagraph 
showed calcification in the adrenal 
glands and discrete and dense opaci¬ 
ties at the hila of the lungs suggest¬ 
ing calcified nodules. The red-cell 
count was high, 6,492,000, and there 
was a high lymphocyte count sup¬ 
posed to be indicative of lymphatism 
and a bad prognosis. The eosino- 
philes were high, from 5 to 7 per 
cent. The heart was also small in 
this case. Rolleston and Boyd (Brit. 
Jour. Child. Dis., xi, 105, 1914). 

Traumatism of the skin is a predis¬ 
posing cause to pigmentation. The 
earliest melanodermic patches are 
often noted to appear over old cica¬ 
trices, especially over the healed areas 
of former blisters, and even the appli¬ 
cation of a blister or merely of a 
poultice on an asthenic subject is 
often sufficient to cause a sudden 
outburst of pigmentation and permit 
a diagnosis of Addison's disease. 

Gastrointestinal disturbances are fre¬ 
quent, but very variable in nature. At 
the outset, constipation is the rule, and 
is accompanied by anorexia, which may 
be accounted for both by the intestinal 
paresis and by the general lassitude to 
which we have already alluded. The 
constipation may be succeeded, par¬ 
ticularly in the acute forms, by atonic 
diarrhea. But the most characteristic 
symptom is, without doubt, vomiting. 
Preliminary nausea is very seldom 
present; the vomiting comes on sud¬ 
denly, and generally in the morning 
upon awaking. At first the patient's 
stomach is evacuated but once a day; 
then, as the disease progresses, the 
vomiting becomes more frequent and 
occurs at intervals during the day. 
The act takes place with but little 
muscular efifort, of which the subject 


is, indeed, incapable. The vomitus is 
colorless, thin, and consists of mucous. 

Circulatory disturbances are of great 
importance. The earlier observers had 
already pointed out a special weakness 
of the pulse, together with all the 
symptoms of cerebral anemia. The re¬ 
searches of Schafer and Oliver and of 
Langlois and the later investigations 
of the action of adrenalin served to 
direct the attention of clinicians to 
these disorders, at the same time dis¬ 
closing their pathogenesis. 

The Addisonian subject is in a state 
of hypotonicity. By reason of the ab¬ 
sence or insufficiency of the adrenal 
secretion, the normal tonus of the ves¬ 
sels is no longer maintained. Even at 
the outset of the affection, along witlr 
the first signs of asthenia, lowered 
arterial tension is to be found. The 
sphygmomanometer shows 100 to 120 
mm. of mercury. The fall in pres¬ 
sure is accentuated as the disease 
advances; in the last stages, a tension 
as low as 50 mm. may be noted. 

Bernard and Sergent have brought 
out a clinical phenomenon which they 
claim to be useful in diagnosis without 
the aid of instruments of precision, 
viz., the “adrenal white line”—as op¬ 
posed to the red line of meningitis. To 
cause it to appear, the skin of the 
abdomen is lightly rubbed with the pulp 
of a finger, without scratching; after a 
few moments a rather broad white 
streak appears, which becomes more 
and more marked, remains stationary 
for three to four minutes, then grad¬ 
ually fades off. 

In cases showing rapid develop¬ 
ment there was an increase of urea— 

2 grams or thereabouts—although the 
kidneys showed no lesions, macro- 
scopical or histological, at the autopsy. 
Sicard and Haguenau (Paris Med 
May 23, 1914). 


ADDISON’S DISEASE (LANGLOIS). 


335 


Pain and Nervous Disturbances .— 
Lumbar and abdominal pains of great 
severity may be present at the outset of 
the disease. They frequently become 
localized in the epigastric and hypo¬ 
chondriac regions, and Martineau has 
described a pathognomonic seat of pain 
at the anterior extremity of the eleventh 
rib. These pains, however, almost 
characteristic when they are sudden in 
onset, are sometimes entirely wanting 
throughout the course of the disease. 
When considering the pathogenesis of 
the affection, we shall find it easy to 
understand how the variations ob¬ 
served in the painful phenomena may 
be explained according to the extent 
and the seat of lesions surrounding the 
adrenals. 

We have already mentioned the as¬ 
thenic manifestations, which, according 
to us, are referable rather to the mus¬ 
cular system than to the nervous sys¬ 
tem proper, or at least to the structure 
which unites the nerve with the mus¬ 
cle—the terminal plate (as formerly 
designated) or the receptive substance 
of Langley. True paralyses are rare 
and in no sense characteristic. Cere¬ 
bral disturbances, such as the pros¬ 
tration, the tinnitus aurium, the hal¬ 
lucinations, and especially the en¬ 
cephalopathy of Addison’s disease, 
may be due to two causes i cere¬ 
bral anemia resulting from vascular 
hypotonicity, and intoxication either 
through suppression of the antitoxic 
activity of the adrenals or through 
the formation of toxic products owing 
to functional deficiencies—asthenia, hy¬ 
potonicity, etc. 

General Disturbances. —The muscu¬ 
lar and vascular weakness are neces¬ 
sarily followed by disorders of a gen¬ 
eral nature. The chemical interchanges 
are reduced, the phenomena of assimi¬ 


lation greatly retarded, whence result 
marked wasting of the tissues and a 
strongly manifested sensation of cold 
generally accompanied by hypothermia. 
According to the view of Sajous, who 
considers Addison’s disease as char¬ 
acterized by deficient oxidation and 
lowered metabolism, a study of the 
temperature should enable us to judge 
of the degree of adrenal insufficiency. 

The blood in cases of Addison’s dis¬ 
ease presents nothing peculiar. The 
search for pigment in the blood-plasma 
has always proved negative. Gener¬ 
ally the blood-cells show diminution, 
but observations on this subject have 
been contradictory. While Laignel- 
Lavastine described diminutions of 
the corpuscles to three millions, 
Loeper and Crouzon found a polycy¬ 
themia. Langlois, in a comparative 
study of twa tuberculous cases pre¬ 
senting similar pulmonary lesions, 
but one of whom showed distinct 
Addison’s disease, observed no dif¬ 
ference either in the hemoglobin 
percentage, the number of cells or 
the proportion of leucocytes. The 
two patients gave identical results. 

The secretion of urine is diminished 
because of the lowered tonicity. Cola- 
santi and Bellati, who made a study of 
the urine of an Addisonian patient for 
eighteen days, found its toxicity above 
that of normal urine. Langlois did not 
find this abnormal toxicity in the two 
subjects of which he made a compara¬ 
tive study. 

Course and Termination. —Addison’s 
disease always terminates fatally, but 
its course may be more or less rapid. 
Sometimes the destruction of the adre¬ 
nals is so quickly produced that the 
morbid phenomena show very rapid 
progression. Asthenia is present al¬ 
most from the outset, the circulatory 


336 


ADDISON’S DISEASE (LANGLOIS). 


disturbances at once become very 
marked, and, lastly, the gastrointes¬ 
tinal disorders, which do not appear 
to be closely related to the adrenal 
insufficiency, may become of such 
severity, with intractable vomiting 
and diarrhea, that cachexia and death 
supervene before the melanodermia 
has had time to declare itself. 

In the cases having a slow course, the 
disease may remain stationary for a 
long time, and -it is in such cases that 
are sometimes observed temporary pe¬ 
riods of improvement not only with 
regard to the digestive tract, but also 
in the symptoms of melanodermia: 
asthenia and arterial tension. The 
cause of such periods of improvement 
it is difficult to state. 

Combined Addison’s disease and 
exophthalmic goiter was observed by 
the writers. When the suprarenal 
glands are insufhcient, the thyroid 
may come to their aid, by increasing 
its own functioning. In 26 cases of 
Addison’s disease they obtained a 
thyroid reaction in 4. In 1 of these 
in this group, the thyroid enlarged 
about 6 months after the visible on¬ 
set of Addison’s disease. Tachycar¬ 
dia, tremor and other symptoms of 
exophthalmic goiter became super¬ 
posed; as they developed, the symp¬ 
toms of Addison’s disease became at¬ 
tenuated. This sequence of clinical 
phenomena was so striking, they ac¬ 
cepted it as a suggestion for organo¬ 
therapy, and since then have been 
giving patients with Addison’s dis¬ 
ease 0.5 Gm. (734 grains) of pulver¬ 
ized suprarenal tissue and 0.01 Gm. 
(Ve grain) of thyroid powder in the 
morning, fasting for 6 days. Then 
they drop the thyroid, keeping on 
with the suprarenal treatment for 10 
days and then continuing with 10 
days of the 2 combined, and so on. 
The outcome was not very clear in 
some of the cases, but in 3 the im¬ 
provement was marked. Ramond 
and Francois (Jour. Amer. Med. 


Assoc., from Bull de la Soc. Med. des 
Hop., Nov. 16, 1917). 

We shall lay no stress on the mode 
of death by progressive cachexia, which 
presents nothing peculiar, but must 
dwell with some emphasis upon the 
form of death which takes place rapidly 
or even suddenly. 

The rapid fatal termination in Addi- 
son^s disease takes on the features of 
an acute intoxication. The abdominal 
pains show marked exacerbation; diar¬ 
rhea becomes profuse and vomiting 
continuous, the blood-pressure at the 
same time showing progressive reduc¬ 
tion. 

In some cases hypothermia is ob¬ 
served, with a tendency to collapse; in 
others, on the contrary, there occurs 
hyperthermia accompanied by delir¬ 
ium and convulsions. 

To explain this sudden aggravation 
in the course of the afifection, several 
hypotheses have been put forth. That 
one which appears to us the most ad¬ 
missible among them is based on a sud¬ 
den diminution, sometimes even on al¬ 
most complete suppression, of the func¬ 
tion or rather the functions of the 
adrenals. Almost always, indeed, such 
an unfavorable turn in the disease suc¬ 
ceeds upon an intercurrent infection. 
Now, since the researches of Charrin 
and Langlois, followed by those of 
Loeper and others, it has been known 
that certain infections, such as diph¬ 
theria and scarlatina, exert a selective 
action on the adrenal glands, causing 
in them a more or less marked func- 
donal deficiency. It is thus plain that 
if in a gland already the seat of tuber¬ 
culosis, but which, nevertheless, suffices 
to insure the adrenal function, a fresh 
lesion appears to destroy the surviving 
cellular elements the symptoms of ad¬ 
renal insufficiency will show a sudden 


ADDISON’S DISEASE (LANGLOIS). 


337 


outburst and be seen in all their inten¬ 
sity. Boinet has also laid stress on the 
appearance of serious accidents after 
excessive fatigue. Such occurrences 
confirm the investigations of Abelous 
and Langlois and of Albanese upon the 
influence of fatigue on experimentally 
decapsulated animals. 

Another theory accounts for the ag¬ 
gravating efifect of intercurrent infec¬ 
tions from the fact that, the antitoxic 
action of the adrenals against certain 
toxins no longer being exerted, the 
accidents due to intoxication are more 
severely manifested. It is evident that 
this hypothesis explains better than the 
former the phenomena of excitation, 
viz., delirium, convulsions, fever. 

Sudden death, or at any rate death 
taking place within a few minutes, is 
not rare in the bronzed disease, and 
Addison had already referred to such 
a termination in his monograph. In 
1896 Ihler was able to collect 18 cases, 
and since that time numerous instances 
have been noted. Certain cases of sud¬ 
den death in apparently healthy persons 
have defied explanation until the au¬ 
topsy disclosed a tuberculous or can¬ 
cerous process of the adrenals. 

The advent of death may be truly 
fulminating; a patient previously ex¬ 
hibiting no signs of aggravation in his 
condition may drop dead while getting 
out of bed or on attempting to lift 
a chair. The patient of Dupaigne- 
Beclere, who was among the first to be 
treated with relative success by opo¬ 
therapy, died suddenly in bed during 
her convalescence. In some cases the 
end is marked by symptoms of a more 
striking character, such as a sudden 
attack of severe vomiting, convulsions, 
etc. The pulse becomes frequent and 
thready; the face cyanosed; dyspnea 
develops, and death occurs. 


Accidental syncope, nervous shock, 
acute intoxication, and sudden adrenal 
insufficiency have all been advanced as 
hypotheses in explanation of such oc¬ 
currences. It is difficult to believe, in 
this connection, that adrenal insuffi¬ 
ciency can produce so rapid an effect 
since it is well known that completely 
decapsulated animals survive for fifteen 
to eighteen hours and show progress¬ 
ively increasing intensity before death. 
It appears to us more reasonable to 
attribute the termination to nervous 
shock originating in the adrenal or peri- 
adrenal sympathetic nerves, and react¬ 
ing on the general organism with its 
cardiac and vascular inefficiency result¬ 
ing from decreased tonic activity on the 
part of the adrenals. 

Case of Addison’s disease in a ne- 
gress, aged 55 years. The face and 
backs of the hands and fingers were 
intensely black—much blacker in hue 
than other parts of the body. The 
palms of the hands were also abnor¬ 
mally pigmented, but to a lesser de¬ 
gree than the face. There were nu¬ 
merous irregularly defined areas of 
pigmentation on the mucous mem¬ 
brane of the cheek, gums, and tongue. 
Her pulse was frequent, small, and 
regular. 

At the necropsy the vagina showed 
evidence of chronic inflammation of 
its mucous membrane and presented 
patches of pigmentation similar in 
character to those present in the 
mouth. On the vulva were a few 
small leucodermic areas. Both supra- 
renals were enlarged and exhibited 
caseous masses in their substance, 
apparently affecting the cortex. Their 
capsules were much thickened and 
adherent to the surrounding parts. 
They contained caseating masses, at 
the margin of which were giant cells, 
in the cortex. The condition was 
tubercular, with tendency to caseation. 
R. Seheult (Lancet, Aug. 3, 1907). 

Three cases of Addisonism occur¬ 
ring in the same family, in sisters. 


1—22 


338 


ADDISON’S DISEASE (LANGLOIS). 


aged 9, 6, and years, respectively. 
The father, mother, and an elder sis¬ 
ter, aged 19 years, were all healthy. 
The case of the girl aged 9 years was 
one of true Addison’s disease. Groom 
(Lancet, Feb. 27, 1909). 

Clinical Varieties .—Several forms of 
Addison's disease have been described 
according to the relative prominence 
of certain symptoms. These include 
the gastrointestinal form, painful 
form, melanodermic form, and as¬ 
thenic form. These divisions are 
worthy of acceptance because they 
correspond in each case to a develop¬ 
ment and pathogenesis differing from 
the others. It seems probable, indeed, 
that in the melanodermic as well 
as in the painful form sympathetic 
changes predominate from the outset, 
while, in the asthenic form, adrenal 
insufficiency is the primary cause. 

According to Finkelstein, of Paris, 
Addison’s disease in infancy is not 
rare, occurring in sucklings as well as 
in later months. Most cases are due 
to tuberculosis of the adrenals, al¬ 
though some cases have been asso¬ 
ciated with the perfectly normal 
glands. The most important symp¬ 
tom is pigmentation of the skin, al¬ 
though pigmentation may be brought 
about by a long-continued diarrhea 
in infants. Other symptoms are gen¬ 
eral depression and extreme weakness, 
diarrhea and vomiting, and convul¬ 
sions. The pulse is weak and irregu¬ 
lar. The disease is always fatal, dis¬ 
solution being due to weakness, or to 
some intercurrent disease, especially 
tuberculosis. 

Addison’s disease in children. Be¬ 
fore puberty, ie., under 13 years, it 
presents considerable differences from 
that above this age, and is extremely 
rare. Analysis of 25 cases, including 
a personal one. As to relative fre¬ 
quency, Monti found among 200 cases 


6 in children below 13, while Green- 
how in 330 found it four times; in 
other words, 1 to 62. 

Etiology .—The main etiological factor 
is tuberculosis, though the patient of 
Anglade and Jaquin showed no such 
lesion in the adrenal glands, although 
extensive tuberculosis in the lungs 
and spinal cord was present. Age: 
Twelve cases occurred between the 
ages of 10 and 13 years, 4 cases 
between 5 and 10, while 9 occurred 
below the age of 5. The youngest 
case on record is that of Belyayeff, of 
a child 7 days old. Contrary to what 
textbooks state, that the disease oc¬ 
curs far more frequently in boys than 
girls, the occurrence in males and 
females is about equal. 

Family History .—Tuberculosis occur¬ 
red as a family taint in 4 cases; in 
one instance a rheumatic history; in 
one instance the mother and four 
children had had the disease. 

Previous History .—In 13 cases in 
which this was obtained there was 
tuberculosis of other organs in 3, 
measles in 2, scarlet fever in 2, ton¬ 
sillitis and chorea in 1. Felberbaum 
and Fruchthandler (N. Y. Med. Jour., 
Aug. 10, 1907). 

Hypoglycemia should be included 
among the symptoms of Addison’s 
disease, as a corollary to the arterial 
subtension. Bernstein (Berl. klin. 
Woch., Oct. 2, 1911). 

The writer found 6 cases on record 
in which the right suprarenal capsule 
was absent; in 2 Addison’s disease 
developed, as the other suprarenal de¬ 
veloped tuberculosis. He has recently 
seen a third case of aplasia of the 
right suprarenal. Schnyder (Schweizer 
med. Woch., July 14, 1921). 

PATHOGENESIS. — The patho¬ 
genesis of Addison’s disease cannot 
be explained except by referring to 
the data of physiology, and, while 
Addison was deserving of high credit 
for pointing out the relation of the 
bronzed disease to changes in the 
adrenals, the pathogenesis none the 
less remained obscure because the 


ADDISON’S DISEASE (LANGLOIS). 


339 


functions themselves of the adrenals 
were still unknown. 

Two important theories have been 
advanced, which, moreover, do not 
refer exclusively to lesions of the 
adrenals, but to which recourse is 
also had to explain the morbid syn¬ 
dromes related to lesions of all duct¬ 
less glands, including the thyroid 
gland, the pancreas, etc. These are: 
1. The nervous theory, which at¬ 
tempts to explain all the phenomena 
by an action of the nervous system 
through its adrenal connections. 2. 
The glandular theory, which attrib¬ 
utes the disturbances to functional 
alterations in the adrenals. 

Nervous Theory. — The nervous 
theory had already been clearly stated 
in Addison’s second paper, which 
pointed out the close relations exist¬ 
ing between the solar plexus, with the 
semilunar ganglia, and the adrenals. 
In France, Jaccoud became a strong 
partisan and defender of this theory. 
After him and after Addison, Haber- 
shon, Barlow, Schmidt, Mattei, and 
Martineau attributed the nervous 
disturbances observed to lesions of 
the solar plexus and semilunar gan¬ 
glia. Following Jaccoud, this view is 
still held by Greenhow, Jurgens, von 
Kahlden, Lancereaux, Raymond, and 
Brault. These authors offer as argu¬ 
ments, on the one hand, changes in 
the adrenals in cases where during 
life the subject had exhibited none of 
the symptoms referable to Addison’s 
disease and, on the other hand, the 
normal condition of the adrenals in 
individuals declared to have Addi¬ 
son’s disease before the autopsy. 

Jaccoud supported the theory on 
the basis of three orders of facts: 
the symptoms observed, the lesions 
found post mortem, and the structure 


of the adrenal glands. Among the 
symptoms observed, leaving the mel- 
anodermia out of consideration at 
once, the nervous disturbances are of 
two kinds: increasing asthenia and 
the gastric or nervous manifestations. 
Prof. Jaccoud, after referring to these 
symptoms, adds: “If we now bear in 
mind that in the uncomplicated cases 
these symptoms show progressive 
development in the absence of any 
important visceral lesion, without 
anemia, without albuminuria, without 
hemorrhage, and without diarrhea, 
they will without doubt appear to us 
as the direct and immediate result of 
a disturbance of the nervous system.” 
We shall see later that these asthenic 
phenomena cannot be brought forth 
as arguments in favor of the nervous 
theory, and that the capsular theory, 
as conceived by Abelous and Lan- 
glois, itself finds strong support in 
the asthenia of Addison’s disease, de¬ 
scribed by Jaccoud. 

The autopsy in a case of Addison’s 
disease in a child of 10 years showed 
tubercular infiltration of the lungs 
and enlargement of the bronchial 
glands. The suprarenal capsules were 
congested, but macroscopically they 
presented no lesions. A microscopic 
examination revealed no change in 
the histological structure. The cap¬ 
sule was of normal thickness, and the 
gland, as a whole, was not enlarged. 
The nuclei of the cells were distinct 
and there was no fatty degeneration. 
The semilunar plexus was somewhat 
altered and congested. The mesen¬ 
teric glands were large, but not case¬ 
ous. Upon examination the Bacillus 
tuberculosis was absent. Richon (Arch, 
de med. des enfants, tome vi. No. 
6, p. 350, 1903). 

In every case of true Addison’s dis¬ 
ease there is a gray degeneration of 
the nerve-fibers of the splanchnics. 
This may be either protopathic, when 
one finds simple atrophy of the ad- 


340 


ADDISON’S DISEASE (LANGLOIS). 


renals without other inflammatory 
appearances in these or other organs, 
or (more commonly) deuteropathic, 
in consequence of primary disease of 
the adrenals or pancreas. Withing- 
ton (Med. News, Sept. 24, 1904). 

Report of a typical case in which 
the lesions were located in the solar 
plexus, the suprarenals being free 
from tuberculosis. Laignel-Lavastine 
and Porak (Bull, de la Soc. Med. des 
Hopitaux, July 5, 1918). 

The attacks of vomiting and the 
epigastric and lumbar pains are, in¬ 
deed, in favor of nervous lesions, and 
it can readily be understood how the 
close proximity of the sympathetic 
nervous structures may explain the 
motor and sensory disturbances ob¬ 
served in cases of bronzed disease. 
As for the structure of the adrenals, 
it does not permit of our forming any 
definite opinion. 

While it is quite true that these 
glands receive a large number of 
nerve-fibers from the sympathetic, 
as shown by the researches of Nagel, 
Bergmann, Kolliker, and Plenle, there 
exist in the cortical layer ganglionic 
cells which may constitute reflex 
centers (Moers, Joesten, Holm); 
and while it is true that excitation of 
the adrenals tends to inhibit the in¬ 
testinal movements (Jacob), yet the 
role of the adrenal bodies cannot be 
denied, even on the ground of their 
texture alone. The main argument 
against the pathogenetic role of the 
adrenals is based on the following 
double series of observed facts: Mel- 
anodermia may exist without lesions 
of the adrenals; marked lesions of 
the adrenals may exist without 
melanodermia. 

Glandular Theory .—The researches 
of Brown-Sequard, which followed 
the monograph of Addison at an 


interval of but a few months, were 
steeped in the idea which then pre¬ 
vailed as to the ‘'predominance of 
melanodermic disturbances in the 
bronzed disease.” Furthermore, while 
unable to observe pigmentation of the 
skin in animals deprived of their 
adrenals, he pointed out the presence 
of numerous pigmentary granulations 
in the blood. The most prominent 
result of his researches, however, lay 
in the discovery of the functional 
importance of the adrenals, of which 
the role had until then escaped physi¬ 
ologists. “Death resulting from 
changes in these organs,” wrote this 
author, “is preceded by a gradually 
developing weakness, going on to 
paralysis of the posterior extremities, 
then of the anterior, and finally of 
the respiratory muscles. Among the 
disorders noted may also be men¬ 
tioned anorexia, failure of digestion, 
rather frequently delirium, epilepti¬ 
form disturbances, and a gradual 
lowering of the temperature.” Brown- 
Sequard concluded that destruction 
of the adrenals was followed by ac¬ 
cumulation in the blood of a toxic 
substance having the property of 
becoming transformed into pigment. 
Since 1855 the investigations on the 
adrenals have been numerous. The 
conclusions of Brown-Sequard have 
been vigorously attacked. Philip- 
peaux, Gratiolet, Harley, Berutti, and 
Martin-Magron combated the vital 
role of the adrenals, asserting, con¬ 
trary to the belief of Brown-Sequard, 
that destruction of these organs did 
not necessarily result in death. 

Tizzoni, in numerous researches 
carried out between the years 1884 
and 1889, likewise recognizes the pos¬ 
sibility of survival after destruction 
of both adrenals; but he points out at 


ADDISON’S DISEASE (LANGLOlS). 


341 


the same time the possibility of regen¬ 
eration of these organs when not 
totally destroyed; finally he referred 
to medullary disorders succeeding 
upon destruction of one adrenal. 

Stirling showed that in a certain 
number of cases survival after de¬ 
struction of both adrenals is explained 
by the presence of accessory adrenals. 
Alezais and Arnaud ascribed the fatal 
ending to ascending degeneration 
reaching the cord by way of the 
splanchnics. 

Clinical and autopsy findings in 
3 cases: The morbid changes in 
the suprarenals were accompanied by 
corresponding changes in the other 
glands with an internal secretion, the 
thyroid, hypophysis, and spleen—all 
of these were hypertrophied, with 
evidence of hyperfunctioning. The 
writer does not regard Addison’s dis¬ 
ease as due to a single gland, but to 
several participating in the process. 
The first symptom in one patient was 
tremor of the arms, probably the re¬ 
sult of professional exposure to elec¬ 
tric currents, the man’s work being 
done under an electric light of be¬ 
tween 15,000 and 20,000 candlepower. 
The effect of the Roentgen rays on 
glandular organs suggests that the 
light here may have affected the cer¬ 
vical sympathetic, the thyroid, and the 
hypophysis. Later the process seems 
to have extended to the abdominal 
sympathetic and suprarenals. In an¬ 
other case atrophy of the ovaries fol¬ 
lowed a pregnancy with premature 
menopause. Calcareous degeneration 
of the thyroid followed, with tuber¬ 
culous infection later and fulminating 
suprarenal symptoms. The diseased 
suprarenals could not obtain help 
from the ovaries and thyroid, and 
there was merely slight hyperfunc¬ 
tioning of the hypophysis as a de¬ 
fensive reaction. In the 3 cases 
patients in the last stages of Addi¬ 
son’s disease recovered their energy 
and the bronzing subsided under thy¬ 
roid treatment. The thyroid was al¬ 


ready modified and was inadequate to 
supplant the diseased suprarenals, but 
it only required slight additional aid 
from without to be able to counteract 
temporarily the destructive process in 
the suprarenals. The disease, the 
course, the outcome, the histologic 
findings, the research in the experi¬ 
mental field, all sustain the assump¬ 
tion that Addison’s disease, in its com¬ 
plete form, is a general affection of 
the entire great sympathetic system. 
Leonardi (Policlinico, Aug., 1909; 
Jour. Amer. Med. Assoc., Oct. 2, 
1909). 

In 1891, Abelous and Langlois 
published their first researches on the 
functions of the adrenals in frogs; 
these were followed by a series of 
papers on the functions of the glands 
in other animals. They showed that, 
in all animals subjected to double 
adrenalectomy, death promptly and 
inevitably occurs, but that a portion 
of an organ if left behind is sufficient 
to cause survival. Muscular weak¬ 
ness and asthenia are all the more 
intense if the animal be forced to per¬ 
form muscular movements, whence 
their first conclusion “that the ad¬ 
renals possess the function of neu¬ 
tralizing or destroying toxic sub¬ 
stances evolved during muscular 
labor.” This conception of the role 
of the adrenals explains a portion of 
the symptoms observed in Addison’s 
disease, including the most charac¬ 
teristic symptoms: asthenia and the 
disastrous effects of fatigue. 

The discovery of the vasoconstrict- 
ing action of suprarenal extract by 
Oliver and Schafer, on the one hand, 
and Cybulski, on the other, that of 
the presence of the active substance in 
the blood of the capsular vein (Cy¬ 
bulski and Langlois), that of the 
rapid destruction of this substance in 
the organism (Langlois), and finally 


342 


ADDISON’S DISEASE (LANGLOIS). 


the isolation of adrenalin by Taka- 
mine also threw new light on the 
symptoms observed. The lowered 
vascular tension and the cerebral 
disorders can henceforth be inter¬ 
preted as resulting from diminution 
of the tonic influence of the adrenals. 
The syndrome of adrenal insufficiency 
in its entirety can henceforth be ex¬ 
plained through the data of experi¬ 
mental physiology. 

Study of the nitrogen and sulphur 
metabolism in a patient who had Ad¬ 
dison’s disease and who was on a 
purin-free diet. The desamidating 
capacity of the patient (capacity to 
reduce amid nitrogen) and his capac¬ 
ity to transform the sulphur of the 
cystin group into sulphuric acid were 
absolutely comparable to that of nor¬ 
mal individuals. A considerable de¬ 
gree of acidosis was observed, which 
is not accounted for by any factor 
which was found in this examination. 
The endogenous metabolism of the 
patient, as represented by the kreati- 
nin and uric acid outputs, was below 
that of normal subjects. Wolf and 
Thacher (Arch, of Int. Med., June, 
• 1909). 

The writer, who had previously ob¬ 
served a striking hypoglycemia after 
removal of the adrenals, now reports 
the effect upon the glycogen content 
of the liver and muscles of the same 
procedure. Seven dogs were killed 
at intervals of four and one-half to 
eight hours after removal oJ the ad¬ 
renals. At this time all showed great 
muscular weakness. Their livers con¬ 
tained an average of 0.722 per cent, 
glycogen. If one animal be excluded, 
the average of the other six was 0.222 
per cent. Schondorff found 18.69 to 
7.3 per cent, of glycogen in the livers 
of normal dogs on a similar diet. The 
muscle content of glycogen was 0.653 
per cent., compared with Schondorff’s 
average of 4 per cent. In three dogs 
dying spontaneously after operation, 
the livers contained no glycogen what¬ 
ever, the muscles an average of 0.187 
per cent. The lack of glycogen is the 


cause of the hypoglycemia. The mus¬ 
cular weakness is, in all probability, 
due to lack of sufficient sugar and 
sugar-producing material, for muscle 
glycogen is well known to be far less 
readily available for the body than is 
the liver glycogen. Forges (Zeit. f. 
klin. med., Bd. Ixx, S. 243, 1910). 

Adrenalin glycosuria is due to the 
conversion of liver glycogen into su¬ 
gar. In animals rendered glycogen- 
free by starvation and strychnine poi¬ 
soning, adrenalin injections cause a 
new formation of glycogen and sugar. 
Pollack (Arch. f. exper. Path. u. Phar- 
mak., Bd. Ixi, S. 149, 1909). 

Even the insufficiency or complete 
failure of adrenal opotherapy finds 
its explanation in the instability of 
suprarenal extracts. (We retain this 
vague term to convey the fact that 
adrenalin is but one of the principles 
now isolated which are elaborated by 
the adrenals). 

But while physiology can explain 
and experimentally reproduce most 
of the symptoms of Addison’s disease 
—those which Bernard and Sergent 
classify in the syndrome of pure 
adrenal insufficiency—she has shown 
herself entirely powerless to repro¬ 
duce and explain the pigmentation 
which is so characteristic of this 
affection. 

Excepting in one observation by 
Boinet, no experimenter has been 
able to produce pigmentation experi¬ 
mentally, either by destroying the 
adrenals or by setting up local irrita¬ 
tion. 

Following Loeper we shall refer 
into four groups the theories which 
have been advanced to explain mel- 
anodermia: adrenal origin, cachectic 
origin, nervous origin, and mixed 
glandular and sympathetic origin. 

A. Adrenal Origin .—The elabora¬ 
tion of a pigment by the secretion of 


ADDISON’S DISEASE (LANGLOIS). 


343 


the adrenals, thought of by Brown- 
Sequard and Pfandler, and which 
would be caused by lesions of the 
organ itself, is not supported by any 
evidence of value. The hemolytic 
function of the gland and the accumu¬ 
lation in the blood of pigment derived 
from hemoglobin when the glandular 
function is weakened are likewise too 
hypothetical. 

B. Cachectic Origin (Gubler, Teis¬ 
sier, Debove).—It is certainly true 
that any cachexia may provoke, along 
with general nutritional disorders, 
pigmentary phenomena. But the 
bronzed disease is frequently mani¬ 
fest previous to the establishment of 
cachexia, and presenting features 
which give it a specific character 
which does not bear well with the 
general processes of the cachexia. 

C, Nervous Origin .—The intimate 
connections existing between the 
adrenals and the sympathetic system 
are such as to warrant a belief in 
functional changes in this system 
during Addison’s disease. Addison 
had already thought of the possible 
role of the nervous system. Jaccoud, 
Lancereaux, and Raymond defended 
this theory. 

The clinical observations of Sem- 
mola and of Brault, who noted mel¬ 
anoderma in conjunction with sim¬ 
ple compression of the semilunar 
ganglia and solar plexus, and the 
cases of Addison’s disease with 
lesions of but one adrenal (Green- 
how) are cited as favoring the view 
of nervous origin. Irritation of the 
sympathetic would presumably bring 
about an overproduction of pigments, 
either in the blood itself (von Kahl- 
den, Nothnagel), in the chromoblasts 
(Raymond) or in the cells of the 
epidermis (Behier, Chatelin). 


D. Mixed Origin .—Attractive as the 
nervous theory may be, it does not 
suffice in all cases, and especially is 
in complete disagreement with ex¬ 
perimental facts, since all excitations 
of the sympathetic, whether extra- or 
intra- capsular, have proven without 
effect in producing melanodermia. A 
number of physicians are at present 
adopting the opinion of Loeper, that 
melanodermia is the result of changes 
both in the adrenals and the nervous 
network surrounding them. Accord¬ 
ing to Loeper, the adrenal secretion is 
the normal and necessary exciting 
agent of the nervous system in its 
function of regulating pigmentation. 
Sajous (1903) and Laignel-Lavastine 
hold an opposite view: the sympa¬ 
thetic is not the regulator of pigmen- 
togenesis, but of the adrenal gland 
itself, on which the formation of 
pigment depends. 

Two cases, pronounced hypoplasia 
of the chromaffin system, accom¬ 
panied the typical Addison’s disease, 
while the lymph-glands were enlarged. 
V. Werdt (Berl. klin. Woch., Dec. 26, 
1910). 

Case of chronic Addison’s disease 
in a youth with the thymolymphatic 
temperament. The suprarenals had 
been totally destroyed by a primary 
tuberculous process, as also in a simi¬ 
lar case in a man of 41 with the status 
lymphaticus. Analysis of these cases 
and of similar ones in the literature 
seems to demonstrate a mutual stim¬ 
ulating action between the thyroid 
and the suprarenals and between the 
thyroid and the thymus, while there 
is mutual inhibiting action between 
the suprarenals and the thymus. 
Kahn (Virchow’s Archiv, June, 1910). 

Case of male fern poisoning in 
latent Addison’s disease. The rem¬ 
edy was given with castor oil for a 
tape-worm. The autopsy showed 
tuberculosis of the adrenals—a true 
Addison’s disease. Most of the cases 


344 


ADDISON’S DISEASE' (LANGLOIS). 


of poisoning by male fern are those 
in which employment of the drug has 
been followed by the administration 
of castor oil. The use of the com¬ 
bination is strongly warned against. 
F. Schotten (Munch, med. Woch., 
Nov. 3, 1914). 

[I have long urged that the adrenals 
took part in the autoprotective functions 
of the body, and that when they were dis¬ 
eased poisoning occurs more readily. 
Hence also the vulnerability of such cases 
to infection. C. E. de M. S.] 

DIAGNOSIS. —The various symp¬ 
toms encountered in Addison’s dis¬ 
ease may be divided into two groups: 

A. Symptoms of adrenal insufficiency. 

Cardiovascular disturbances;— 

Lowered arterial tension. Tachy¬ 
cardia. 

White line on abdomen. 

Cerebral anemia. Syncope. 

Disturbances of metabolism :— 

Lowered temperature and sensation of 
cold. 

Progressive asthenia. Wasting. Pros¬ 
tration. 

Encephalopathy and various nervous 
disorders. Vomiting and diarrhea. 

B. Symptoms of irritation of the adrenal 
sympathetic. 

Melanodermia. 

Radiating pains. 

Vomiting and diarrhea. 

Where the Addisonian syndrome 
is complete and the course rapid, the 
diagnosis is easily made. It becomes 
more -difficult when melanodermia is 
absent or doubtful. A study of the 
resistance to fatigue, either by means 
of the ergograph or by simply caus¬ 
ing the patient to perform a definite 
piece of work, combined with the use 
of the sphygmomanometer, may be 
of value in facilitating diagnosis, but 
very often in the hospital, in cachectic 
tuberculous subjects, the involvement 
of the adrenals is not discovered till 
the autopsy. 


In fact, the question of diagnosis is 
generally raised when it becomes 
necessary to attribute the melano- 
dermic patches to Addison’s disease 
or, on the other hand, to some 
other affection producing pigmentary 
changes, such as the pigmentation of 
cachectic tuberculous cases, pigmen¬ 
tation of hepatic origin, the melano-. 
dermias of malaria, arsenic poisoning, 
lead poisoning, and phthiriasis. 

The most common fallacy is to mis¬ 
take Addison’s disease for pernicious 
anemia; the peculiar lemon tint of the 
skin in the latter condition, however, 
is different from that of the charac¬ 
teristic case of Addison’s disease; but 
in slight cases confusion often arises. 
Fortunately, modern means of exam¬ 
ination of the blood, which in Addi¬ 
son’s disease is but little abnormal, 
enable the recognition of the marked 
blood characteristics of pernicious 
anemia. 

The writer, however, advises cau¬ 
tion against being content with 
negativing a diagnosis of pernicious 
anemia because a single blood exam¬ 
ination fails to show characteristic 
changes. The blood in pernicious 
anemia varies from day to day and 
from hour to hour. 

Another possible source of confusion 
commonly met with, is the discolora¬ 
tion consequent on prolonged admin¬ 
istration of arsenic. By inquiry of 
many persons of considerable experi¬ 
ence in arsenical poisoning the 
writer finds that the occurrence of 
pigmentation in the mouth is in favor 
of the case being Addison’s disease. 
In malignant disease the wasting is 
apt to be much more marked, and 
local evidence of malignancy can 
usually be found. • 

Other pathological conditions some¬ 
times confounded with Addison’s 
disease, but w-hich ought to be easily 
distinguishable, are the filthy, dirty 
patients, infested with lice, sometimes 
seen in hospital out-patient depart¬ 
ments; phthisical and syphilitic pig- 


ADDISON’S DISEASE (LANGLOIS). 


345 


mentation; Hanot’s cirrhosis of the 
liver, and bronzed diabetes. 

Any condition that destroys the 
functional activity of the medullary 
part of the suprarenals may cause Ad¬ 
dison’s disease, by far the most com¬ 
mon being tuberculous degeneration. 
Calmette’s reaction helps in this mat¬ 
ter. The comparative frequency of 
malignant disease as a cause, the au¬ 
thor considers due to the necessity of 
having both suprarenals affected, and, 
perhaps, to the fact that in malignant 
disease death will be occasioned be¬ 
fore the evolution of characteristic 
phenomena. The proportion of cases 
in which clinically characteristic Ad¬ 
dison’s disease has failed to show dis¬ 
ease of the suprarenals is so small, 
about 12 per cent., as to be within 
the margin of allowable error due to 
erroneous diagnosis, inefficient post¬ 
mortem examination, or the possibil¬ 
ity of functional disturbance of the 
suprarenals. Further, other glands, 
c.g., the internal carotid and the coc¬ 
cygeal, have cells functionally resem¬ 
bling those of the suprarenals, and it is 
conceivable that very rarely disease 
of these glands may cause Addison’s 
disease and lead to death before the 
suprarenals are affected. On the other 
hand, when the suprarenals have been 
found to be diseased, and yet no Ad¬ 
dison’s disease has been present, it 
may be that the vicarious activity of 
these other glands may have formed 
sufficient internal secretion to prevent 
the patient having Addison’s disease. 
W. H. White (Clinical Journal, Mar. 
18, 1908). 

The melanodermia of phthisical 
patients is all the more likely to lead 
one astray because of the fact that 
the cases of Addison’s disease are 
almost all tuberculous. For some 
authors, moreover, the majority of 
melanodermic tuberculous cases are 
cases of Addison’s disease in which 
the adrenal changes are just begin¬ 
ning, not yet showing the signs of 
glandular insufficiency, but having 


pericapsular lesions which cause a 
precocious melanodermia. In pig¬ 
mented tuberculous subjects without 
Addison’s disease the pigmentation is 
said to be of a lighter grade and 
especially the mucous membranes to 
be unaffected. 

Three cases of tuberculosis of the 
suprarenals in which there was no 
pigmentation. The diagnosis was 
made in two from the remarkable 
weakness of the patients in strong 
contrast to their well-nourished as¬ 
pect. Another sign is the low blood- 
pressure, not to be explained to any 
disturbances on the part of the heart. 
Gastrointestinal disturbances without 
traceable cause are further corrobora¬ 
tive testimony. These findings differ¬ 
entiate Addison’s disease even with¬ 
out pigmentation of skin or mucosae. 
Stursberg (Munch, med. Woch., Bd. 
liv, Nu. 16, 1907). 

Cases of liver cirrhosis and even a 
few incipient hepatic cases without 
appreciable change in the size of the 
liver present either disseminated he¬ 
patic patches of discoloration or a 
diffuse melanodermia of the same 
color as in Addison’s disease. Here 
again the mucosae are but slightly or 
not at all involved, and the hepatic 
disorders place one on the right track. 

Arsenical pigmentation is a rare 
occurrence; the same is true of sat¬ 
urnine pigmentation. In the latter 
the blue line on the gums is generally 
sufficient to permit diagnosis. In 
pigmentation due to arsenic, the color 
is more slaty in hue, and a dark mot¬ 
tling is also present, which is rather 
characteristic. Finally the signs of 
arsenical intoxication, together with 
the absence of those of adrenal in¬ 
sufficiency, serve to establish the 
diagnosis. 

In malarial subjects the pigmenta¬ 
tion again does not involve the mu- 


346 


ADDISON’S DISEASE (LANGLOIS). 


cous membranes, it is more diffuse 
and uniform, and the special indica¬ 
tions of malaria are present. 

The melanodermias of phthiriasic 
origin (pediculosis) seen among vaga¬ 
bonds in a state of physiological de¬ 
bility, and who are bearers of para¬ 
sites, are accompanied by itching and 
cutaneous excoriations. The causa¬ 
tive agent may be discovered. 

On the whole, it should be borne in 
mind that the melanodermia of Addi¬ 
son’s disease differs from other forms 
of pigmentation in that it shows 
marked preference for mucous mem¬ 
branes, although this characteristic 
should not be put down as absolutely 
distinctive. 

Early diagnosis is all important, 
though often very difficult. The dis¬ 
ease gives rise to definite signs and 
symptoms, and usually to marked le¬ 
sions of the medulla of the suprarenal 
gland. The solar plexus is frequently 
diseased, owing to the influence of 
the secretion of the gland in stimulat¬ 
ing the sympathetic system. Pathog¬ 
nomonic signs are asthenia, pigmen¬ 
tation, vomiting, and attacks of faint¬ 
ness. If these symptoms are well 
marked the diagnosis is not difficult, 
but when they have become evident 
the chances of successful treatment 
are not good. Grunbaum (Practi¬ 
tioner, Aug., 1907). 

Two personal cases which empha¬ 
size the resemblance existing between 
Addison’s disease and tabes dorsalis. 
Both patients presented an almost 
identical pigmentation, and both had 
muscular atrophy. One was a typical 
case of Addison’s disease, while the 
presence of tabes was undoubted in 
the other. It is not necessary to as¬ 
sume a combination of tabes dorsalis 
with Addison’s disease, however, since 
other symptoms of the last-named 
affection were lacking. The pigmen¬ 
tation should rather be referred to 
tabetic changes of the nervous sys¬ 
tem. Possibly the pigmentation in 


Addison’s disease is likewise the ex¬ 
pression of disease on the part of the 
nervous system. In this particular 
instance atrophy of the shoulder mus¬ 
cles was said to have been present 
ever since birth, and atrophy of the 
thigh muscles was claimed to have 
followed later, in connection with 
traumatism. Wagner (Berl. klin. 
Woch., Nu. 15, 1908). 

TREATMENT. — Addison’s dis¬ 
ease of pure type or manifested in the 
syndrome of adrenal insufficiency 
without melanodermia is largely 
caused by tuberculosis of the ad¬ 
renals. The general treatment of 
tuberculosis, or rather that form of 
treatment which is in vogue in a 
given locality at the time, is indi¬ 
cated. Syphilis of the adrenals is 
rarely diagnosticated during life; at 
the autopsy may be found either ex¬ 
tensive gummata, a miliary syphilo- 
sis or, especially in the young, a 
sclerosis resulting in atrophy of the 
gland. In doubtful cases the effect 
of specific treatment may be tried. 
Certain cases seem to have been bene¬ 
fited by the iodides, with or without 
the addition of mercury (Schwytzer, 
A. Andrews). 

. Cases of bona fide acute adrenitis 
with or without hemorrhage, which 
are almost always frankly infec¬ 
tious in origin (small-pox, diph¬ 
theria, etc.), generally run a very 
rapid course and do not possess any 
special line of treatment. As for the 
morbid growths—sarcoma, epithe¬ 
lioma, carcinoma, etc.—which it is 
almost impossible to diagnosticate 
during life, unless perhaps it be when 
persistent edema is noted in com¬ 
bination with the usual syndrome, 
surgical intervention is indicated, 
though the results obtained by Israel, 
Mayo, Kelly, Lecenne, and Hart- 


ADDISON’S DISEASE (LANGLOIS). 


347 


mann have afforded but little en¬ 
couragement. 

Physiological data naturally led to 
the trial of adrenal opotherapy. This 
treatment was first instituted by 
Abelous, Charrin, and Langlois in the 
form of a glycerin extract of the 
adrenals of guinea-pigs, dogs, and 
horses. The patients were in such a 
state of cachexia that no results were 
obtained, but in two less advanced 
cases, employing injections each rep¬ 
resenting Gm. 0.10 of the dried ex¬ 
tract, Langlois obtained better results 
and in particular a notable diminution 
of the asthenia. 

Since that time numerous trials have 
been made and the treatment mark¬ 
edly altered. Among the methods 
that have been tried are: 1. Hypo¬ 

dermic injections of the extract. 2. 
Ingestion of fresh or dried glandular 
substance. 3. Injection of adrenalin 
solution. 4. Grafting of adrenal 
tissue. 

1. The injections of extract of the 
suprarenals were early abandoned 
because of the great pain they occa¬ 
sioned and the fact that they failed to 
give satisfactory results in a large 
number of cases. 

2. The ingestion of fresh or dried 
gland has furnished a few unhoped¬ 
for results, together with numerous 
failures. Beclere and Anderodias re¬ 
port cases of cure, or, perhaps better, 
disappearance and long-continued ab¬ 
sence of the symptoms of adrenal 
insufficiency. It is advised to use the 
adrenals of calves and start with 
doses of Gm. 1.5 to 2.0, which are 
gradually increased to Gm. 6.0. 
Sajous employs the dried gland (the 
glandulae suprarenales siccae of the 
U. S. P.). The dried extract may be 
given in capsules in the dose of Gm. 


0.25 to 0.35 daily for ten successive 
days; it is left off for four days, then 
resumed for six to eight days, etc. 
Systematic testing with the sphygmo¬ 
manometer should be used, as a guide 
in the treatment. Improvement in 
the arterial tone is to be considered 
the sign of efficiency in the treatment, 
while any indication of hypertonicity 
demands immediate stoppage of the 
administration of adrenal. 

Adamses paper in the Practitioner for 
October, 1903, includes an analysis 
of 97 cases treated with a preparation 
of the suprarenal glands. Of these, 7 
were distinctly made worse by the 
treatment, 43 derived no benefit, 31 
showed marked improvement, and 16 
were cured. 

The methods in the use of glands 
in these cases may be divided 
into five heads: 1. Suprarenal grafts. 
Three patients were treated by this 
method and all died. 2. Nine pa¬ 
tients were treated by fresh glands 
given by the mouth; of these, 1 be¬ 
came worse, 1 was not benefited, 6 
were improved, and 1 permanently re¬ 
lieved. 3. Eleven patients were 
treated by hypodermic and intramus¬ 
cular injection. One became worse, 
6 derived no benefit, 3 were improved, 
and 1 permanently benefited. 4. 
Sixty-one cases were treated with the 
fluid or solid extract of the suprarenal 
gland by the mouth. Of these, 2 were 
made worse, 32 derived no benefit, 17 
were markedly improved, and 10 were 
permanently relieved. 5. Five pa¬ 
tients were treated by mixed meth¬ 
ods; 3 were improved and 2 cured. 

The cases most likely to derive bene¬ 
fit from the specific treatment are 
those in which the process is a chronic 
sclerosis and in which the other or¬ 
gans are fairly sound. D. Symmers 
(Med. News, Sept. 10, 1904). 

Series of 120 cases collected from 
literature, including 97 previously col-* 
lected by E. W. Adams, in all of which 
adrenal preparations had been used in 
some form, gave the following results: 


348 


ADDISON’S DISEASE (LANGLOIS). 


1. Cases in which death can be as¬ 


cribed to grafting or adrenal 
preparations . 8 

2. Cases in which the benefit was 

slight or nil . 51 

3. Cases in which marked improve¬ 

ment occurred . 36 

4. Cases in which permanent bene¬ 

fit was obtained . 25 


120 

Analysis of these cases shows that 
far better results could be obtained by 
a careful adjustment of the dosage to 
the actual needs of each individual case. 
Addison’s disease being due, from the 
writer’s viewpoint, to inadequate oxy¬ 
genation and metabolic activity, the re¬ 
sult in turn of a deficient production of 
the adrenal secretion, it follows that 
the temperature and blood-pressure in¬ 
dicate the degree to which the adrenals 
are still performing their functions. It 
is plain, therefore, that our aim should 
be to supply only just enough adrenal 
extractive to compensate for the defi¬ 
ciency of adrenal secretion produced. 

The 25 cases of Addison’s disease in 
which, out of the 120 referred to above, 
permanent benefit occurred include one, 
treated by Bate, in which but 412 grain 
(0.005 Gm.) of adrenal extract three 
times daily caused very great and last¬ 
ing improvement with marked lessening 
of i.he bronzing. When the remedy 
could not be obtained temporarily, 
which occurred twice, the case relapsed. 
On the other hand. Suckling began with 
10 grains daily and gradually increased 
until 175 grains were given each day, 
and also obtained favorable results. 
That in Bate’s case the adrenals were 
still able almost to carry on their func¬ 
tion is self-evident, while in Suckling’s 
the remedy practically compensated for 
the adrenals (while the local morbid 
process in them was still active, and 
such as to paralyze their functions—a 
fact A/ell shown by the severity of the 
case when the use of the extract was 
begun). The average dose is probably 
that used by Weigall in a very severe 
case—5 grains, increased to 10 grains, 
of the extract three times a day. The 
patient increased 6 pounds in two 


weeks, and after about three months 56 
pounds. In other words, in the 25 
cases of permanent benefit, although 
the remedy was used empirically, it so 
happened in all probability that the 
doses employed coincided with the needs 
of the organism. In the 51 cases in 
which no benefit was obtained several 
occur in which failure was evidently 
due to inadequate dosage or to too early 
cessation of the treatment, while in 
others excessive doses—practically in 
every instance a too rapid or excessive 
increase of the dose—as clearly pre¬ 
vented a successful issue. Sajous 
(Monthly Cyclo., April, 1909). 

3. The injection of adrenalin rec¬ 
ommended by Netter and Sergent ap¬ 
pears to us best suited for the cases 
showing low arterial tension, whether 
of adrenal origin or not. 

4. Grafting of adrenal tissue. The 
only rational treatment for adrenal 
insufficiency is grafting of the gland. 
Experimentation shows, indeed, that 
the substances secreted by the gland 
are very quickly destroyed in the 
organism, and that either the inges¬ 
tion or injection of the extract can, 
therefore, produce but very evanes¬ 
cent effects, which, besides, cannot 
completely replace the activities as 
yet unknown having their seat in the 
glandular cells themselves. Unfor¬ 
tunately, success in adrenal grafting 
is not easily obtained, and in cases 
where the vitality of the grafted 
gland has manifested itself accidents 
of so grave a nature have been noted 
that grafting has been considered an 
impracticable method. Courmont re¬ 
ports 3 cases of the grafting of dogs’ 
adrenals in man and states that in 
all of them the results were disas¬ 
trous. His personal case developed 
a formidable hyperthermia and car¬ 
diac collapse. 

Sajous has collected from the gen- 






ADDISON’S DISEASE (LANGLOIS). 


349 


eral literature 120 cases of Addison’s 
disease treated by opotherapy in its 
various forms and presents the fol¬ 


lowing table:— 

1. Cases in which death can be ascribed 

to grafting or adrenal preparations . 8 

2. Cases in which benefit was slight or 

nil . 51 

3. Cases in which marked improvement 

occurred . 36 

4. Cases in which permanent benefit was 

obtained . 25 


120 

In a typical case reported by the 
writer in a woman of 35 years, ad¬ 
renal gland, tuberculin every 10 days, 
and iron and arsenic, caused im¬ 
provement, the blood-pressure rising 
from 95 to 110. In 6 weeks the pa¬ 
tient was very well, and went to the 
country. She soon relapsed, however, 
and the treatment was repeated with 
no good effect. During a period in 
which she was very weak and low, 
transplantation of an adrenal was 
performed. On March 17th a male 
patient died of heart disease. The 
cadaver was taken immediately to 
the anesthetising room adjoining the 
operating theater, and the right ad¬ 
renal removed and placed in normal 
saline solution at 100° F. In the op¬ 
erating theater cocaine and adrenalin 
solution was infiltrated over the 
lower ends of the patient’s recti ab¬ 
dominis. A longitudinal incision was 
made on each side, and the sheaths 
of both right and left recti laid open. 
The adrenal was bisected, and half of 
the gland was then buried in each 
rectus muscle. The sheaths of the 
recti were then closed with contin¬ 
uous catgut sutures, and the skin 
wounds with horse hair. The patient 
was very ill after the operation, but 
from 21st March improved rapidly. 
By 2d April she was up, and was at 
the time of writing in comparatively 
good health. The pigmentation was 
distinctly less, and she had gained 
one stone (14 pounds) in weight. 
The blood-pressure on the 19th June 
was 104. D. Murray Morton (Aus¬ 
tral. Med. Jour., July 6, 1912). 


In a typical case of Addison’s dis¬ 
ease observed by the writer, the pa¬ 
tient’s weight had come down from 
186 to 95 pounds. None of the 
remedial measures used were of the 
least avail. He was then placed upon 
fresh adrenal glands from the sheep, 
taking them raw and minced. As he 
developed repugnance to these desic¬ 
cated gland was substituted. The 
improvement was striking, all the 
symptoms showing change for the 
better. He had recovered 50 pounds 
of his weight, and his improvement 
otherwise was harmonious, when 
suddenly and without apparent cause 
acute gastritis set in, with prostra¬ 
tion. It was found that he had sus¬ 
pended his adrenal treatment for 
over 3 weeks. His stomach was un¬ 
able to retain anything. Cerebral 
symptoms now set in and death took 
place from coma. The lesson of this 
case is that we have not sufficiently 
tested organotherapy in these cases. 
Klein (Deut. med. Woch., Aug. 1-8, 
1912). 

True Addison’s disease can often be 
benefited, and sometimes even recov¬ 
ered from, at least in its glandular 
manifestations (its most important 
ones) by adrenal opotherapy, which 
not only makes up for deficiency of 
secretion, but also leads to a com¬ 
pensatory hypertrophy which to 
some extent replaces lost glandular 
tissue. Sergent (Jour, de Med. et de 
Chir. Prat., June 10, 1913). 

A typical case of Addison’s disease 
in 1902, cured with adrenal gland, left 
as only symptom a discrete melano- 
dermia. Eleven years later the pa¬ 
tient died of gastric cancer. The 
autopsy showed a small cicatrix in 
the left adrenal. Hirtz and Debre 
(Paris Med., June 27, 1914). 

In a case of advanced Addison’s 
disease observed by the writer, an 
intravenous injection of adrenalin 
caused sweating over the entire body 
and then sudden arrest of both the 
heart and the respiration. Only after 
half an hour’s vigorous artificial 
respiration was the patient revived. 
In another case an intravenous injec- 






350 


ADENITIS (WITHERSTJNE). 


tion was followed by intense tremor 
and pallor, and the left side of the 
face alone was bedewed with sweat. 
Lowry (Med. Klinik, Nov. 1, 1914). 

Exceptional cases as regards the 
extreme tolerance of the patient for 
epinephrin. The man of 38 with 
grave symptoms of suprarenal in¬ 
sufficiency was given 10.5 mg. (14 
grain) epinephrin in four and a half 
hours; this included 2 mg. (142 grain) 
subcutaneously and 8.5 mg. (14 grain) 
intravenously. ' No sugar appeared in 
the urine and the blood-pressure was 
not brought up quite to the normal 
figure even with this. The following 
days 6 and 4 mg. (14o and He grain) 
were given. There were no signs of 
intolerance at any time, even though 
to attain the desired therapeutic re¬ 
sult these large doses were found 
necessary. The case teaches that we 
need not shrink from large doses of 
epinephrin in emergencies, as with 
acute suprarenal insufficiency under 
chloroform, or with gaseous gangrene 
or other hypotony of infectious 
origin. By watching over the blood- 
pressure as the epinephrin is being 
taken, we can continue it and push it 
until the arterial pressure is brought 
up to a point where the functioning 
of the organs is possible once more. 
Nolf and Fredericq (Arch. Med. Bei¬ 
ges, Aug., 1917). 

Two cases treated by the writer 
retrogressed even to the pigmenta¬ 
tion of the mucous membranes under 
tonics and systematic administration 
of suprarenal gland. The patients 
were men of 65 and 70 who had been 
subjected to great privations. The 
suprarenal deficiency had evidently 
been merely functional. Quincke 
(Therap. Halbmonatshefte, Jan. 15, 
1920). 

If tuberculosis is suspected the 
treatment of this condition should 
also, according to Sajous, be resorted 
to. 

In a case observed by the writer 
suspected of tuberculous origin, the 
patient’s sister having died of tuber¬ 
culosis, the patient was treated in 


the usual climatic and general hy¬ 
gienic way, and in addition received 
several courses of tuberculin injec¬ 
tions. The patient is in good health 
and able to perform rather arduous 
duties. Munro (Brit. Med. Jour., 
Mar. 23, 1912). 

[The administration of adrenal gland 
alone often fails to cure. In truth, adrenal 
gland should be regarded only as an im¬ 
portant adjunct to the treatment of the 
causative disorder, and an agency calcu¬ 
lated to compensate for the reduced secre¬ 
tion the diseased adrenals produce. C. E. 
DE M. S.] 

J. P. Langlois, 

Paris. 

ADENTIIS. -DEFINITION.— 

Inflammation of a gland. 

VARIETIES. —Adenitis may be 
acute, due almost invariably to infection 
from an attack of angioleucitis and oc¬ 
casionally to- injury or strains; or 
chronic, resulting from either of the 
preceding, especially in strumous or 
cachectic persons, and from slight 
sources of irritation, and not uncom¬ 
monly resulting in permanent enlarge¬ 
ment and induration or in tuberculous 
degeneration. Adenitis of specific ori¬ 
gin will be described under Syphilis 
and Urinary System. 

ACUTE ADENITIS. 

SYMPTOMS. —The general symp¬ 
toms depend upon the extent and 
severity of the infection. Rigors may 
occur when pus forms. The tempera¬ 
ture is frequently elevated. If the in¬ 
fection is severe, symptoms of pro¬ 
found septicemia appear. 

The local symptoms are, by far, the 
most prominent in the majority of cases, 
and consist of pain, heat, and swelling. 
The suffering varies from a slight sore¬ 
ness only to intense pain according to 
the position of the gland, its relations 
with the surrounding tissues, and the 


ADENITIS (WITHERSTINE). 


351 


density of the tissue in which it is im¬ 
bedded. The heat may vary according 
to the degree of the congestion present. 
The swelling may either be great or 
slight. If the lesion be confined to the 
gland, it will be well defined; if peri¬ 
adenitis is present, the swelling will be 
more or less difluse. Glands in any re¬ 
gion of the body may be affected, but 
those of the neck, axilla, and groin 
more than the others; this is due to the 
fact that infection generally enters the 
system through the mouth, throat, 
genital organs, and the extremities. 

In the congestive, or exudative, stage, 
pain and swelling are present in the 
region of the glands; if the glands are 
superficial the swelling is ovoid, with 
the long axis coinciding with the direc¬ 
tion of the afferent lymphatics, and pal¬ 
pation reveals several movable, hard, 
elastic, and tender rounded masses. 

When the glands are deep, as in the 
axilla, abdomen, or even the neck, the 
results of palpation are less definite and 
unsatisfactory. 

In the suppurative stage the pain in¬ 
creases and becomes sharp and catch¬ 
ing, the skin reddens, and the periglan¬ 
dular tissue swells. 

If the gland alone suppurates, the 
skin remains normal, while under it 
may be felt the softened and enlarged 
gland. This latter opens outwardly or 
into the neighboring cellular tissue on 
from the sixth to the fifteenth day of 
the affection. When the gland opens 
outwardly, the cicatrix is much smaller 
than when it ruptures into the cellular 
tissue, as in the latter case it gives rise 
to an abscess. 

If the cellular tissue around the gland 
suppurates, the skin becomes quite 
hot, swollen, and painful, and fluctua¬ 
tion may be felt. Two foci of suppu¬ 
ration are thus established. The skin 


is occasionally undermined by the 
pus. Recovery is possible, however, 
without suppuration of the gland. 

Both the gland and the cellular tissue 
around it may suppurate, either simul¬ 
taneously, or suppuration of the cellular 
tissue may precede that of the glands, 
or the latter may suppurate and rupture 
into the surrounding cellular tissue and 
form an abscess. Pus is usually pro¬ 
duced in considerable quantity, and the 
affection is of long duration. 

Suppurative adenitis may result in 
cicatrization after several weeks. This 
cicatrix may reopen to allow the exit of 
pus from a suppurated gland. On the 
other hand, a fistula may result, which 
may give exit to seropus or to lymph 
(Despres). A lymphatic gland or 
vessel will then be found at the bottom 
of the abscess cavity, below the crater¬ 
like opening. 

As the suppuration usually starts in 
more than one focus in the gland, the 
first sensation to the touch will be one 
of bogginess, which periglandular con¬ 
gestion may render obscure. Well- 
defined fluctuation is found only when 
considerable tissue is destroyed. 

Two cases of adenitis of the elbow 
due to fever were observed by the 
writer. In the one case staphylococci 
were found in the pus evacuated from 
the epitrochlear lymph-node in a con¬ 
valescing young child. The germs 
may have entered by a small wound 
of the thumb. In the second case 
of the same kind the epitrochlear 
lymphadenitis subsided without sup¬ 
puration under systematic application 
of wet compresses. It was probably 
a primary typhoid lesion. L. Ver- 
delet (Jour, de Med. de Bordeaux, 
Apr. 21, 1912). 

DIAGNOSIS. —The diagnosis of 
ordinary superficial acute adenitis is 
usually easy; it is more difficult when 
the neighboring cellular tissue is also 


352 


ADENITIS (WITHERSTINE). 


inflamed; it may be impossible in cases 
of deep-seated or visceral adenitis. 

In adenitis of the inguinocrural re¬ 
gion the swelling is found in the ex¬ 
ternal portion of the region if due to a 
lesion of the gluteal tissues, and in the 
inner portion of the region if due to a 
lesion of the anus, perineum, or external 
genitals. In both conditions the tumor 
will have its long axis directed more or 
less horizontally. 

The swelling will be found in the 
lower portion of the inguinocrural re¬ 
gion, with the long axis directed more 
or less vertically, if the lesion causing it 
is situated on the foot, leg, or lower 
part of the thigh. This disposition is 
due to the anatomical relations of the 
lymphatic vessels and glands, and 
should be borne in mind. Operation 
for strangulated crural (femoral) 
hernia has been performed for an 
adenophlegmon of the crural canal. 

Supraclavicular adenitis, while fre¬ 
quent in phthisis, is not present in every 
case. Yet it is of great diagnostic value 
when present. There may be a few or 
a great number of slightly enlarged 
glands, and they are frequently bilat¬ 
eral. The cervical glands may also be 
enlarged. There is no pain, nor does 
the swelling increase, remaining just 
the same for years. They rarely ac¬ 
company apical tuberculosis, but are 
generally found with peripheral, sub- 
pleural lesions. The writer considers 
that the presence of enlarged supra¬ 
clavicular glands confirms the diagnosis 
of doubtful phthisis. C. Sabourin 
(Jour, des praticiens, Dec. 27, 1902). 

New sign described, based on aus¬ 
cultation at level of seventh cervical 
or first dorsal vertebra. When the 
child speaks in a low voice the voice 
sound is accompanied by an added 
whispering sound, localized to one or 
two vertebrae, or extending even to 
fourth or fifth dorsal vertebra. It is 
present long before dullness appears. 
The bronchial quality of respiration 


over this area is also significant, but 
it only appears when the glands are 
considerably enlarged. The absence 
of abnormal breath sounds and apical 
rales affords corroborative evidence. 
D’Espine (Brit. Med. Jour., Oct. 15, 
1910). 

ETIOLOGY. —The lymphatic glands 
serve as reservoirs on the course of the 
lymphatic vessels, through which any 
irritants or infection must pass. 

Glandular enlargement indicates an 
infective process situated in the 
lymph tissue specifically drained by 
such glands. In most cases of acute 
associated infection the glandular en¬ 
largement subsides as soon as .the 
infective process is removed. When 
chronic cervical glandular enlarge¬ 
ment persists in spite of local treat¬ 
ment of the throat the lymph tissue 
involved—the tonsils—is frequently 
the seat of a tuberculous lesion, the 
glands being secondarily infected. 
E. B. Gunson (Brit. Jour. Child. Dis., 
Oct.-Dec., 1917). 

Cold and overexertion act as local 
depressants, and thus may indirectly 
favor the development of adenitis. Gen¬ 
eral debility has the same efifect. The 
following varieties of adenitis, etiolog- 
ically regarded, are recognized:— 

1. Adenitis by contiguity, resulting 
from the propagation, by contact, of a 
neighboring inflammation. 

2. Adenitis by continuity or follow¬ 
ing lymphangitis. 

3. Adenitis by embolism, due to the 
transportation of septic or irritating 
matter, produced in the system or com¬ 
ing from the outside. 

Adenitis of the mesenteric glands 
may be due to dysentery or to the 
inflammation of Peyer’s patches in 
typhoid fever. 

Adenitis occurs in carbuncle, furun¬ 
cle, vaccination, erysipelas, and eruptive 
or infectious fevers. 

Attention has been called by many 


ADENITIS (WITHERSTINE). 


353 


observers to the frequent association 
of enlargement of the cervical glands 
and diseased tonsils. So often has this 
been found that every patient suffer¬ 
ing from cervical adenitis should have 
the tonsils examined, with a view to 
their removal if diseased. The con¬ 
tents of the tonsillar crypts should be 
examined microscopically, and the 
identity of the bacterial growths 
therein ascertained. It is wise to sub¬ 
mit the tonsillar mass to bactericidal 
measures— e.g., iodine in glycerin— 
some time before removing them. 

The writer made histological ex¬ 
aminations of 65 whole tonsils re¬ 
moved from children; 57 tonsils of 
patients not clinically tuberculous 
showed no tuberculous lesions. Of 
eight patients with tuberculous cervi¬ 
cal adenitis the tonsils were found tu¬ 
berculous in 5. F. S. Matthews (An¬ 
nals of Surg., Dec., 1910). 

A child with enlarged tonsils and 
adenoids is not ill because of the in¬ 
creased size, but because of a chronic 
infection of its faucial and post-nasal 
lymphoid tissue, which serves not 
only as a nidus for the manufacture 
of toxins, but also as a port of entry 
for many other systemic diseases. 
This condition of chronic infection, 
which is extremely common, is easy 
to diagnose if the 3 cardinal physical 
signs—enlarged tonsils, rhinitis, and 
enlarged cervical glands—are kept in 
mind. Running ears, bronchitis, mas¬ 
toiditis, etc., are physical signs to be 
noted, more correctly described as 
complications. The disease is highly 
infectious, as shown by the facts: 

(1) That it is far more frequent 
among school children than among 
children who do not go to school; 

(2) that when one child in a family 
is attacked the disease subsequently 
spreads to others who were previ¬ 
ously healthy; (3) micro-organisms 
can always be grown from the nasal 
and post-nasal secretions, which are 
normally sterile. There is a tendency 
to chronicity, the child in such case 

1 - 


being a “carrier” and consequently 
a source of danger to other children. 
P. W. Leathart (Brit. Med. Jour., 
Feb. 14, 1920). 

PATHOLOGY. —If suppuration 
does not occur, resolution may take 
place, or chronic enlargement of the 
gland may follow hyperplasia of the 
connective-tissue stroma of the gland. 

If suppuration does occur the sur¬ 
rounding connective tissue may, and 
usually does, suppurate; then the 
more or less disintegrated gland lies 
in a suppurating cavity formed by 
the circumjacent connective tissue. 

There are two forms of acute ade¬ 
nitis, depending upon the degree of 
inflammation present:— 

1. Exudative adenitis. In this form 
the gland is swollen, and it feels hard 
and elastic. On section it appears red¬ 
dish brown, like the spleen, with small 
foci of hemorrhage, all of which indi¬ 
cate excessive dilatation of the capil¬ 
laries. The lymphatic stream is ar¬ 
rested by the dilatation of the cortical 
lymph-sinuses and their obstruction 
by fibrin, granular material, and por¬ 
tions of altered white corpuscles. The 
lymph-follicles are filled with fibrin 
and accumulated lymph-cells. The 
stroma of the gland is swollen and 
infiltrated with cells. 

If the section of the gland is 
scraped, a milky liquid will be ob¬ 
tained, which contains white corpus¬ 
cles and epithelial cells, the latter 
showing several nuclei. 

2. Suppurative adenitis. In this va¬ 
riety the gland softens, its tissues be¬ 
come more brittle, hemorrhagic infil¬ 
tration centers form that soon change 
into yellow, purulent foci. These, at 
first distinctly separate, soon unite, 
forming an abscess within the fibrous 
capsule of the gland. Sometimes the 

-23 


ADENITIS (WITHERSTINE). 


354 

periglandular tissue suppurates, while 
the gland does not. 

The glandular abscess and the peri¬ 
glandular abscess may open externally, 
each one separately or both simulta¬ 
neously. The suppurating gland may 
rupture into the cellular tissue. Occa¬ 
sionally the gland is hard and elastic; it 
may be difficult to separate it from 
its fibrous capsule. The afferent lym¬ 
phatics are enlarged and thickened. 
The lymph-cells and cortical -follicles 
are few in number and have under¬ 
gone granulofatty degeneration. 

PROGNOSIS. —The prognosis is 
usually favorable; it may be unfavor¬ 
able, however, when extensive abscesses 
form in the neighborhood of important 
organs. 

Deep-seated suppurative adenitis may 
give rise to dangerous complications, 
especially in certain regions, like the 
neck and mediastinum, on account of 
the purulent extensions (through bur¬ 
rowing) and the difficulty of evacuating 
the pus. 

Ulceration of the great vessels of the 
neck giving rise to grave hemorrhages 
may also occur. 

TREATMENT. —The first indica¬ 
tion in acute adenitis is tO' remove any 
source of irritation or infection. Any 
wound, abrasion, opening, or any 
natural cavity with which either of 
these may connect should be so treated 
as to bring about absolute local asepsis. 

Enlarged glands of the neck are not, 
primarily, tubercular, and bear the 
slightest relation, if any, to general or 
pulmonary tuberculosis. They are due 
to a mixed infection of pus-producing 
bacilli, and will quickly resolve if the 
source of the infection is removed be¬ 
fore the glandular tissue becomes dis¬ 
organized. If disorganization takes 
place, the gland should be poulticed 
until it is practically liquefied. It should 
then be opened by a stab puncture, emp¬ 


tied and drained by a Briggs cannula. 
Cases seen late with a large mass of 
partially calcified and partially disor¬ 
ganized glands present call for a thor¬ 
ough and extensive dissection. Treat¬ 
ment, other than local, should be food, 
fresh air, and proper clothing. F. D. 
Donoghue (Boston Med. and Surg. 
Jour., Mar. 28, 1907). 

The region in which the affected 
gland is situated should be kept at rest 
and, if possible, elevated. In this man¬ 
ner the afferent arterial current is 
diminished, while the efferent venous 
and lymphatic currents are increased. 

To prevent suppuration, gray mer¬ 
curial ointment, very gently rubbed in, 
is useful. The injections of from 5 to 
10 minims of a 3 per cent, carbolic acid 
solution into an inflamed gland have 
also proven satisfactory. 

If it is desired to hasten suppuration, 
warm antiseptic fomentations are to be 
used in preference to poultices. The 
compound resin cerate of the pharma¬ 
copoeia is effective for this purpose, and 
is antiseptic as well. 

When pus has formed, the gland 
should be opened by a generous inci¬ 
sion, sinuses, if present, being opened 
throughout their entire length to facili¬ 
tate treatment. The contents are then 
carefully removed, and the infiltrated 
wall scraped with a sharp curette. The 
cavity should then be packed with iodo¬ 
form gauze, or gauze impregnated 
with camphorated naphthol or salol. 
The dressing may be removed on the 
third day. 

In addition to climatic and general 
tonic treatment, the writer advised the 
evacuation by puncture of suppurative 
adenitis and the injection of a mixture 
of iodoform, 1 part; ether, 10 parts; 
oil of sweet almonds, 100 parts; creo¬ 
sote. 2 parts. In chronic cases cure may 
bo obtained in two or three months 
after about twenty punctures. Robin 
(Tribune med., xli, 249. 1908). 


ADENLTIS (VVITHERSTINE). 


355 


Balsam of Peru is a valuable curative 
agent, as it is not only antiseptic, but is 
a stimulant to healthy granulation. It 
is applied directly to the open, cleansed 
wound, and then covered with gauze 
and retaining bandage. 

In the treatment of cases of simple 
chronic adenitis, applications of iodine, 
compression, and local blistering have 
given the best results. 

Blisters, nitrate of silver, or iodine 
tincture should be applied around, but 
not over, the inflamed gland. 

Excision may be performed if the 
mass be large or disfiguring. 

In cervical adenitis due to tonsillar 
infection some authors have strongly 
advised the thorough removal of the 
diseased tonsil before attempting the 
external operation upon the glands, 
especially in those cases in which the 
lymph-glands have not broken down. 
The extension of the infection through 
the lymphatics from the tonsils is thus 
checked. 

The writer emphasizes the import¬ 
ance of radiographic study in all 
cases of cervical, facial, and submaxil¬ 
lary adenitis. 

The external appearance of the 
teeth does not constitute reliable evi- 
condition. 

The cooperation of the dental sur¬ 
geon is indicated for the successful 
and expeditious treatment of sub¬ 
maxillary, cervical, and facial ab¬ 
scesses which have their origin in 
dental and peridental infections. B. 
Lipshutz (N. Y. Med. Jour., Mar. 16, 
1921). 

Electricity, preferably the constant 
current, is highly recommended by some 
authors. Daily sittings of ten minutes 
each, using 5 to 15 milliamperes, are 
required, 

Codliver oil, the iodides, and iron 
are indicated in all cases when the 
digestive organs do not rebel against 


their use. Arsenic and strychnine are 
the agents next in order, and sometimes 
prove very effective. Out-of-door life 
and plentiful nourishment are of pri¬ 
mary importance. 

The writer emphasizes the impor¬ 
tance of the relations between the 
glands in the face and neck and the 
teeth, tracing the development of in¬ 
fectious processes including adenitis, 
to the teeth, especially in children. 
Vaccine therapy is extolled when the 
adenitis is once established. If the 
effect of the vaccine in a few hours 
is slight or transient, the presence of 
pus is indicated and requires elimi¬ 
nation before the vaccine can exert 
its efficacy. The focus must be 
drained continuously. He prefers for 
this a loop of fine copper wire, such 
as is used for electric light, the outer 
ends turned back, and the whole held 
in place with a strip of gauze. This 
loop can be inserted and removed 
without inconvenience through a 
minute incision. He prescribes flush¬ 
ing with an antiseptic unless the cav¬ 
ity be sufficient to permit the use of 
the Carrel method. Even when the 
adenitis is only indirectly connected 
with the mouth, the vaccine made 
from the mouth germs still shows 
efficacy. Landete (Arch. Espan. de 
Pediat., Aug., 1918). 

CHRONIC ADENITIS. 

SYMPTOMS.—The symptoms vary 
according to the period of development 
in which the diseased gland is found at 
the time of examination. 

Three periods of development are 
commonly recognized in tuberculous 
adenitis: the period of induration, or 
indolence; the period of inflammation, 
and the period of suppuration. 

1. Period of Induration, or Indo¬ 
lence.—This period may last for years, 
and resolution may even take place, 
though the gland always remains some¬ 
what enlarged and indurated. The 
gland.; are felt as hard, elastic, enlarged 


356 


ADENITIS (WITHERSTINE). 


bodies, rolling under the finger, with 
more or less distinctness as they are 
situated superficially or deep. No heat, 
pain, or redness of the skin is perceived. 

2. Period of Inflammation.—In this 
period we have pain, redness of the 
skin, and tenderness on pressure. The 
gland, if solitary, may adhere to the 
skin. Fluctuation may be present. 

3. Period of Suppuration.—In this 
period we notice much more softening 
of the contents of the gland than a real 
suppuration. The skin may ulcerate 
through almost without inflammatory 
symptoms, and the contents—consisting 
of caseous matter half-dissolved in a 
whitish watery fluid—may be evacuated. 
When periadenitis occurs, true pus may 
be present. 

If chains of glands are tuberculous, 
the latter inflame alternately and dis¬ 
charge their contents in the same order, 
a series of abscesses being thus formed. 

When the contents of the gland are 
discharged, the skin may become ulcer¬ 
ated in the neighborhood, form fistulse, 
and after healing leave a depressed, 
adherent, violet-colored cicatrix. 

In some cases a fistula may form and 
last for years; the skin may be under¬ 
mined, and disfiguring cicatrices may be 
formed. 

Cretaceous transformation occurs at 
times in the deeper glands, but rarely 
in the superficial ones. Some caseous 
glands undergo a process which trans¬ 
forms them into a cyst-like cavity con¬ 
taining a serous liquid. 

In chronic adenitis the glands may 
become painful by the compression of 
small nerves, or of neighboring organs; 
when they are inflamed a small, hard 
mass usually appears, either alone or 
united with others, which may become 
enlarged and suppurate, or persist with 
practically no change for years, or 


finally disappear if the cause of irrita¬ 
tion be removed. 

Chronic adenitis may assume various 
forms. 

1. General Tuberculous Adenitis.— 
This presents itself especially in ne¬ 
groes. Organs other than the glands 
are but little affected, and continuous 
fever exists. The retroperitoneal, bron¬ 
chial, and mesenteric glands are the 
most enlarged. It resembles in many 
ways an acute attack of Hodgkin’s 
disease. 

As long shown by Grancher and 
Marinescu, the majority of children 
presenting symptoms of tuberculosis 
also have general adenitis, the swollen 
glands being felt everywhere; they 
never change in size or consistence. 
Suddenly a bronchitis develops, fol¬ 
lowed by a bronchopneumonia, from 
which the child dies. Microscopical 
examination reveals caseous spots 
and the presence of tubercle bacilli 
throughout the affected glands. 

Cases of cervical adenitis are usu¬ 
ally supposed to be tuberculous, yet, 
according to the writer some may be 
gummatous, and careful study should 
be made to prove or disprove this 
supposition definitely. The clinician 
should obtain an exhaustive history 
of each case to rrrive at a correct 
diagnosis. Coues (Boston Med. and 
Surg. Jour., Nov. 18, 1915). 

To the familiar relation between 
the teeth and the cervical glands the 
writer also adds a mechanical factor 
—the pumping into adjacent tissues 
of debris through loose teeth and 
mastication, an open door for the 
entrance to the glands of tubercle 
bacilli. G. H. Wright (Boston Med. 
and Surg. Jour., Jan. 7, 1915). 

In the majority of cases (80 per 
cent.) of chronic cervical adenitis, 
where no obvious source of infection 
is present, the tonsils are infected. 
The size of the tonsil makes no dif¬ 
ference as to their infectivity, except 


ADENITIS (WITHERSTINE). 


357 


that the small fibrotic variety is likely 
to be more dangerous than the large. 
The organisms are present in the 
deepest parts of the gland. Gardiner 
(Lancet, Oct. 2, 1915). 

The tonsils which are drained by 
their lymphatics into the cervical 
glands frequently contain tubercle 
bacilli. These may penetrate the ton¬ 
sillar membrane without leaving any 
mark. In 50 per cent, of cases of 
tuberculous lymphadenitis, the ton¬ 
sils are also infected. Hence the ton¬ 
sil is an important portal for entry 
of the tubercle bacilli into the human 
organism. W. B. Metcalf (Jour. 
Ophthal. and Oto-Laryn., xi, 71, 
1917). 

[As I have emphasized in the article on 
the Thymus and Lymphatics (in the eighth 
volume) the lymphatic nodes are not 
me-re barriers for bacteria, but protective 
structures in which all kinds of pathologic 
organisms are assailed by phagocytic lym¬ 
phocytes, in order to stay as long as pos¬ 
sible, and perhaps prevent, their penetra¬ 
tion toward the blood-stream. While a 
proportion of enlarged lymphatic glands 
are tuberculous, others may be due to the 
presence in them of other organisms, a 
fact which imposes the necessity in all 
cases of ascertaining the causative agent 
among the many now recognized. The 
foregoing abstracts illustrate this fact. 
C. E. deM. S.] 

2. Local Tuberculous Adenitis.— 

(a) Cervical. This form is usually 
met with in children, and begins in the 
submaxillary glands, which are gener¬ 
ally more enlarged on one side. 

In a study of glands secured from 
110 cases of cervical adenitis, and ex¬ 
amined directly and by culture and 
inoculation, the writer found that of 
these, 10 sets of glands that were not 
tuberculous macroscopically, failed to 
produce infection in guinea-pigs. 
Glands from 29 other cases, all mac¬ 
roscopically tuberculous, and 15 of 
which showed bacilli on direct ex¬ 
amination, all failed to infect guinea- 
pigs, the bacilli being no longer 
active. Glands from 71 cases pro¬ 


duced tuberculosis in guinea-pigs. 
Of these, 37 contained bacilli of the 
human type and the 34 remaining of 
bovine type. 

Analysis of the relative frequency 
of the 2 forms of infection at differ¬ 
ent age periods showed that the pro¬ 
portion of bovine infections was 
greatest in children under 5 years of 
age (90 per cent.), but that the 
bovine type of organism was by no 
means rare in adults over 20 years of 
age (23.5 per cent.). A. S. Griffith 
(Lancet, June 19, 1915). 

(b) Bronchial. This form is thought 
to be always secondary to a focus in the 
lungs, by some authors, but this opinion 
is contested by many others, Osier 
among them. Local lung infection, 
pericardial infection, and general infec¬ 
tion are to be feared, however. 

(c) Peribronchial. In this form we 
must realize the importance of lesions 
resulting from caseation. There is a 
softening of the lymphatic glands situ¬ 
ated around the lower end of the 
trachea and main bronchi. Evidence 
from percussion is of doubtful value; 
alterations in breath-sounds are much 
more important, especially when uni¬ 
lateral; divided respiration, with pro¬ 
longed expiration, is found unaccom¬ 
panied by any adventitious sounds. In 
cases in which the enlarged glands 
ulcerate through the air-tubes, the 
breath has a very offensive odor, and 
coexistence of fetor with hemoptysis 
and evidence of pulmonary consolida¬ 
tion is suggestive. When vomiting of 
blood and its passage by the bowel are 
added, the diagnosis of glands ruptur¬ 
ing into the bronchus and esophagus 
is the most likely one. 

General tuberculous adenitis is 
likely to occur in such cases unless 
prompt treatment is instituted. 

(d) Mesenteric. This form may be 
primary, and is thus very common in 


358 


ADENITIS (WITHERSTINE). 


children, or secondary to local intest¬ 
inal tuberculosis. The suflferers are 
usually weak and wasted; the abdo¬ 
men is enlarged and tympanitic, and 
diarrhea is a common symptom. 
Some fever is usually present. This 
form may exist in adults. 

Sims Woodhead found tuberculous 
mesenteric glands in 78.7 per cent, of 
necropsies on tuberculous children, 
and in 11 per cent, the mesenteric was 
the only lesion present. Colman found 
them in 66 per cent, of the necrop¬ 
sies; Walter Carr in 54 per cent.; 
W. P. S. Branson in 22 per cent. 
When this condition exists in adults, 
it affects oftenest the glands of the 
appendix or of the ileocecal region 
because, according to Corner: 

1. The cecum is like the stomach, a 
resting place for the bowel content. 

2. The bowel contains a maximum 
number of organisms in the cecum. 

3. The lymphoid tissue has its 
greatest development in the ileum, the 
cecum, and especially the appendix. 
Louis Rassieur (Jour. Missouri State 
Med. Assoc., Feb., 1909). 

The recognition of thoracic tuber¬ 
culous adenitis in young children is 
at times very difficult. In 2 instances 
in infants studied by the writer, the 
symptoms from mediastinal glands 
included dyspnea suggesting asthma. 
Laryngospasm occurred. Cough was 
the most constant symptom—a* spas¬ 
modic, dry cough, resembling that 
of whooping cough. Martagao (Bra¬ 
zil-Medico., Feb. 28, 1920). 

The tracheobronchial glands are 
divided into 2 groups. The first or 
pretracheobronchial group lies in 2 
parts alongside the trachea and in the 
superior angle formed by the trachea 
and the large bronchi. The second or 
intertracheobronchial group lies in 
the inferior angle formed by the bi¬ 
furcation of the trachea. Clinical 
physical signs of enlargement of these 
glands are Smith’s sign or venous 
hum over the manubrium of the ster¬ 
num with the head in forced exten¬ 
sion; D’Espine’s sign of bronchophony 
or pectoriloquy below the level of 


the seventh cervical vertebra; Hoch- 
singcr’s sign of glandular enlargement 
in the fourth and fifth intercostal 
spaces in the median axillary line. 
This condition of enlargement of the 
bronchial glands is much more com¬ 
mon in children than in adults, and 
it predisposes to the invasion of the 
tubercle bacillus although the pri¬ 
mary infection may be due to grippe, 
whooping cough, measles, or s 3 q:)hilis. 
A radiograph will either prove or dis¬ 
prove its existence. Trivino (La 
Medicina Ibera, Mar. 20, 1920). 

DIAGNOSIS. —Chronic adenitis is 
generally limited to one or two 
glands; when the glands are tuber¬ 
culous, chronic adenitis is apt to 
affect an entire mass. The former is 
often associated with an external 
simple lesion; the tuberculous form 
is apt to be more frequent in children, 
young soldiers, and negroes. 

A fragment of the suspected tissue 
may be implanted into the subcu¬ 
taneous connective tissue of the groin 
of a guinea-pig, and if the specimen 
is tuberculous a miliary tuberculosis 
will develop in from five to six weeks. 

The use of the tuberculin test in 
the diagnosis of tuberculous adenitis 
is reliable and harmless. The tuber¬ 
culin used is a 1 per cent, solution of' 
Koch’s original product, from 1 to 5 
mg. constituting a usual dose. 

If in from six to twenty-four hours 
after the injection of tuberculin solu¬ 
tion there occur weakness, sensations 
of heat and cold, general malaise, 
nausea, anorexia, severe headache, 
pain in the back and limbs, and if 
these symptoms are sharply defined 
in both their beginning and ending, 
reaction is considered to have oc¬ 
curred. 

Supraclavicular adenitis, while fre¬ 
quent in phthisis, is not present in every 
case. It is, however, of great diagnostic 


ADENITIS (WITHERSTINE). 


359 


value when present. There may be 
few or many slightly enlarged glands, 
and they are frequently bilateral. 

The writer examined over 300 chil¬ 
dren from infancy to 13 years of age 
from the Infants’ Hospital, from a 
large school and from private prac¬ 
tice, X-ray being employed to con¬ 
firm d’Espine’s sign. While the point 
on the vertebral column at which 
whispered voice changes from a 
vesicular to a bronchial character was 
given by d’Espine as taking place at 
the 7th cervical in a few cases, the 
writer found the change as high as 
the 7th cervical, but commonly at the 
1st and 2d dorsal, and frequently as 
low as the 3d without cause. The 
average height was found to increase 
with age. [D’Espine’s sign is described 
on page 352]. 

The writer, therefore, regards as a 
positive d’Espine a change in char¬ 
acter of whispered voice or expiration 
at or below the 3d dorsal. He thinks 
it advisable to think of these glands 
as of those up and down the trachea, 
and of those at the root of the lungs. 
Inflammation of both of the sets will 
give positive d’Espine, dullness ac¬ 
companying those at the root of the 
lungs, and not with glands down the 
trachea unless there is also consolida¬ 
tion at the apex of the lungs. W. W. 
Howell (Amer. Jour. Dis. of Children, 
Aug., 1915). 

Lymphadenoma.—This variety of 
tumor is usually more voluminous and 
is not suppurative. The diagnosis, how¬ 
ever, is exceedingly difficult. 

Simple Adenitis.—This is an acute 
affection usually ending in a few days 
in suppuration. 

Syphilitic Adenitis.—When a pri¬ 
mary sore is present, numerous, small, 
hard, indolent glands can be felt if the 
region is supplied with a chain of lym¬ 
phatics. When in secondary syphilis 
there is glandular enlargement, a large 
number of external lymphatics take 
part in the process. 


Carcinoma.—The enlarged glands 
are small and hard, and can generally 
be distinctly traced to the growth. 

Lymphosarcoma. — This persists 
longer and is much larger before de¬ 
generation occurs. 

Chronic adenitis is frequently a com¬ 
plication of malignant tumors. Supra¬ 
clavicular adenitis appearing during the 
course of visceral cancer is usually situ¬ 
ated on the left side (found 27 times 
on that side by one author). It may 
be solitary or accompanied by adenitis 
in other regions; it usually appears late 
and develops rather rapidly. When 
occurring early it may be very useful 
for diagnostic purposes. 

From a clinical point of view this 
adenitis may be known by its ligneous 
hardness, its painlessness, its freedom 
from adhesions, and by the union into 
one solid mass of all the glands forming 

it- 

ETIOLOGY.—This form of adeni¬ 
tis frequently follows some neighboring 
superficial lesion, such as eczema, 
impetigo, conjunctivitis, or the exan¬ 
themata. Catarrhal inflammation of 
the mucous membranes predisposes to 
tuberculosis of the glands. The resist¬ 
ance of the lymph-tissue is weakened. 
This explains the frequent development 
of tuberculous bronchial adenitis after 
whooping-cough and measles, and of 
mesenteric adenitis in children with 
intestinal disturbances. 

Cervical adenitis is not a manifesta¬ 
tion of an already generalized tuber¬ 
culosis ; the bacillus penetrates, by solu¬ 
tion of continuity of the mucous mem¬ 
branes or the skin, to the ganglion, 
which becomes a seat of infection 
(Duhamel). 

Enlarged glands of the neck are not, 
primarily, tubercular, and bear the 
slightest relation, if any, to general or 


360 


ADENITIS (WITHERSTINE). 


pulmonary tuberculosis. They are due 
to a mixed infection of pus-producing 
bacilli, and will quickly resolve if the 
source of the infection is removed 
before the glandular tissue becomes 
disorganized. 

A distinction should be made between 
hereditary (congenital) and acquired 
tuberculosis. In the latter case the 
author’s views seem rational and cor¬ 
rect, being comparable with and analo¬ 
gous to the phenomena observed in 
carcinoma and syphilis. When the in¬ 
fection is acquired there is, at first, a 
local seat, or focus, of infection in 
which the disease germs develop and 
from which, after proliferation, they 
spread until the disease becomes more 
or less generalized,—the germs being 
transmitted through the lymphatic sys¬ 
tem to the lungs and thence in the 
blood-stream to the various organs of 
the body; the various glands along the 
course or path of transmission become 
affected and in turn become additional 
possible foci of infection. On the other 
hand, when the trouble is hereditary 
the glandular manifestation is an indi¬ 
cation of an already generalized tuber¬ 
culosis. 

Youth predisposes to caseous adenitis 
on account of the predominance at 
that period of the lymphatic system. 
Crowding, humidity, and bad or insuffi¬ 
cient food are also predisposing factors. 
Tuberculous adenitis is frequently ob¬ 
served in temperate regions. Negroes 
brought to such climates are especially 
prone to become sufferers. 

The absorbent power of the lym¬ 
phatic system is so great that the mor¬ 
bific principle of tuberculosis may be 
transported to the glands without visible 
external lesion of the skin or mucous 
membrane. 

Axillary adenitis is frequently sec¬ 


ondary to chronic tubercular lesions of 
the lungs (Lepine). 

The cervical glands are occasionally 
found affected in phthisical patients. 

Observations by Mitchell, of Johns 
Hopkins Hospital, upon 170 cases of 
tuberculous cervical adenitis show the 
disease to be more prevalent among 
negroes than among whites, males pre¬ 
ponderating over females in the pro¬ 
portion of 3 to 2, the majority being 
between 10 and 30 years of age. A 
family history of tuberculosis was pres¬ 
ent in about half the cases, though 6nly 
4 per cent, showed positive evidence of 
the disease in the lungs. The condition 
is regarded as a local manifestation of 
infection through the tonsils, adenoids, 
or carious teeth. 

PATHOLOGY.—Usually an entire 
group of glands is affected. The glands 
are isolated when the irritation and 
rapidity of growth are not great; this 
usually occurs in secondary visceral 
adenitis. In other cases—especially 
when the glands are superficial, where 
the adenitis is primary—the glands are 
united into a large lobulated and irregu¬ 
lar mass, the size of which may vary 
from that of a small nut to that of an 
orange. 

If the adenitis follows a visceral 
tuberculosis the afferent lymphatics 
show, in some cases, signs of tubercu¬ 
losis, as is the case in pulmonary and 
mesenteric tuberculous meningitis. 

Two varieties of lesions are to be 
noted: 1. Lesions of chronic adenitis 
affecting the stroma and the elements 
of the gland, which becomes hyper¬ 
trophied. 2. Specific lesions of tuber¬ 
culosis, consisting .in miliary granula¬ 
tion at first, ending in caseation. As 
one or the other of these two processes 
is the more prominent, so will the lesion 
vary in appearance. Deep adenitis is 


ADENITIS (WITHERSTINE). 


361 


never so sclerous as the superficial 
variety, the latter being characterized 
by a more vigorous reaction. 

On section of a gland in the early 
stage of tuberculous infection we find 
it redder than usual, though at times 
gray and somewhat translucent. The 
tuberculous granules may be perceived 
by a glass. They are formed from the 
vascular and lymphatic vessels found 
in the cortical and medullary portions, 
and resemble ordinary follicles, but 
contain many small cells. Caseation 
rapidly occurs in them, beginning at the 
center of the cells, where giant-cells are 
first formed, proceeding to coagulation 
necrosis and caseation. A number of 
these granulations united form the 
small, yellowish masses, which may be 
seen by the unaided eye. Caseation is 
due to vascular obliteration. 

The small, yellowish masses, softened 
at their centers, are surrounded by 
fibrous tissue due to sclerosis of the 
stroma of the gland. When this tissue 
gives way, several masses form a large 
collection of yellowish, softened mate¬ 
rial resembling putty. Calcification may 
occur when the process is very slow. 

The specific lymphadenitis blocks the 
lymph-spaces and thus, for a time at 
least, mechanically prevents the bacilli 
from penetrating into the general circu¬ 
lation. Glands not in the stream become 
infected, this probably being due to the 
transportation by migrating cells of the 
motionless bacillus. However, infec¬ 
tion usually takes place in the direction 
of the lymph-current. As the lymph- 
spaces are obstructed by inflammation 
products, and entrance of fresh bacilli 
into the gland is thus prevented, it is 
the multiplication of ^ those already 
entered into the gland which gives rise 
to the tuberculosis. When caseation 
occurs, nearly all the bacilli have dis¬ 


appeared, but the spores remain, and 
are capable of reproducing the disease. 
Suppuration is due to a secondary in¬ 
fection by pyogenic micro-organisms. 

The virus of tubercular adenitis is 
less potent, for the caseous material of 
a lymph-gland kills guinea-pigs, while 
rabbits escape, the latter being less sus¬ 
ceptible to tuberculous infection. 

Taken as a whole, tuberculous adeni¬ 
tis (a) is a local disease which may fre¬ 
quently undergo (&) spontaneous reso¬ 
lution, but which (c) frequently tends 
to suppuration, the pus being nearly 
always sterile. It is, however, a con¬ 
stant danger to the system. 

Chronic adenitis may, in some cases, 
be due to continued irritation; ulcers; 
chronic lesions of the skin or mucous 
membrane of the bones; periosteum; 
articulations; chronic inflammation of 
the viscera, and certain new growths 
where the adenitis is purely irritative 
and not yet specific. 

PROGNOSIS.—A chronic adenitis 
may end in resolution, suppuration— 
caseation (see Pathology), cretaceous 
formation, or cyst formation. If all 
the tuberculous matter can be elimi¬ 
nated, either by nature or art, a re¬ 
covery may be obtained. The deeper 
glands are more dangerous than the 
superficial, as they are extirpated with 
more difficulty. The great danger of 
local tuberculous adenitis is that it may 
give rise to other tuberculous lesions, 
either /oca/ (pulmonary phthisis, tuber¬ 
culous osteitis, white swellings, or ab¬ 
scesses) or genera/ (generalized tuber¬ 
culosis, with rapid death). 

Acute miliary tuberculosis may be 
caused in two ways: either by convey¬ 
ance through the lymphatic system 
until the venous system is reached or 
by the perforation of a vein and 
the entrance of tuberculous material. 


362 


ADENITIS (WITHERSTINE). 


TREATMENT.—The general treat¬ 
ment should, in all cases of adenitis, 
receive considerable attention. Good 
food, country air, and sea bathing are 
of the greatest value. 

In peribronchial adenitis the same 
general methods are to be resorted to. 
When due to tuberculosis and kindred 
diatheses and uncomplicated by fever 
or involvement of lung-tissue, the sea¬ 
shore or the country is indicated. At 
the seaside children should not bathe in 
the sea, and should be as quiet as is 
consistent with life in the open air. 
Brisk frictions, milk, a nutritious diet, 
and iodotannic syrup (2 to 4 teaspoon¬ 
fuls per day) are effectual measures. 
After three to four weeks, emulsion of 
calcium lactophosphate and codliver 
oil should be given. Counterirritation 
between the shoulder-blades favors the 
curative action of the other remedies 
(Marfan). Applications of tincture of 
iodine between the shoulders, or in 
some cases blisters or, even better, 
ignipuncture, will fulfill the latter indi¬ 
cations. The syrup of the iodide of 
iron, tincture of iodine, potassium io¬ 
dide, or large doses of codliver oil, 
already mentioned, either alone or 
with cinchona wine, arsenic, or ar- 
seniate of sodium, are the standard 
remedies usually recommended in 
these conditions. Not much is to be 
expected from them, however, unless 
outdoor life is insisted upon. 

Extirpation is indicated when internal 
remedies and X-rays have failed; when 
glands involve the face and produce de¬ 
formity; -when they are isolated and 
few in numbers; when they have un¬ 
dergone fibrous degeneration; when 
they are not freely suppurating. It is 
contraindicated when there is impaired 
general health and tubercular deposits 
in the lungs and joints; when ramifica¬ 


tions of the chain of glands are very 
extensive. 

The writer treated 30 cases of 
tuberculous adenitis with X-rays, and 
obtained prompt recovery. It proved 
so effectual that it can be relied on 
to differentiate ordinary tuberculous 
glands from Hodgkin’s disease, as in 
his 5 cases of the latter disease not 
the slightest benefit was apparent. 
It even seemed, in fact, as if some 
of the cases had been aggravated. J. 
and S. Ratera (Siglo Medico, July 21, 
1917). 

In a group of 48 cases of tuber¬ 
culous glands, complete cure was 
realized in 35. Only 2 others failed 
to show marked benefit, though im¬ 
proved. A great advantage of the 
treatment is that the healing pro¬ 
ceeds without leaving disfiguring 
traces. From 8 to 10 exposures were 
the average course, some cases need¬ 
ing very few and others requiring a 
whole year. The exposures were 
about 4 H. units and the intervals 
about 3 weeks. Van Ree (Nederl. 
Tijdsch. V. Geneesk., Sept. 1, 1917). 

Cervical adenitis is a frequent dis¬ 
ease and deserves more serious con¬ 
sideration. Each case should be 
studied as an individual, and every 
means employed that will produce 
beneficial results. Rontgen rays can 
be expected to relieve completely the 
early cases. Softened glands should 
be opened and drained as abscesses. 
Patients who have been operated 
upon should receive postoperative 
treatment to prevent recurrences. G. 
E. Pfahler (N. Y. State Jour. Med., 
xviii, 99, 1918). 

The end-results in the treatment 
of tuberculous adenitis by X-rays are 
superior to those produced by any 
other method, because radiation is a 
local as well as a constitutional treat¬ 
ment. More cases are permanently 
cured by this method than by sur¬ 
gery alone. Rontgenotherapy never 
spreads the tuberculous process, 
leaves no deformity, and the patient 
always gains in weight and general 
health during treatment. R. H. 


ADENITIS (WITHERSTINE). 


363 


Boggs (Amer. Jour. Roentgenol, v. 
425, 1918). 

Brilliant results reported from 
radiotherapy of tuberculous glands. 
Improvement obtained in all of 470 
cases and a clinical cure in 85 per 
cent, 'within a few months. The more 
malignant processes usually require 
preliminary surgical measures. The 
benign type may be larger, but they 
retrogress under a few exposures. A 
cheesy agglomeration of lymphomas 
may require 6 or 8 exposures at 3- 
week intervals, and after this a few 
treatments at 3-month intervals. The 
cheesy matter can be aspirated 
through a large needle, and any par¬ 
ticularly favorably located single 
gland can be excised. Painful glandu¬ 
lar processes, if solitary, had better 
be excised, followed by 6 exposures. 
If inoperable, the exposures alone 
must be the reliance. When com¬ 
bined with an abscess, the writer ad¬ 
vises incision with 1 exposure a week, 
never exposing red skin; otherwise 
scarring results. Van Ree (Nederl 
Tijdsch. V. Geneesk., Nov. 13, 1920). 

The possibility of giving rise to a 
tuberculous process elsewhere by 
facilitating absorption through ex¬ 
posed tissues should be borne in mind. 

In all cases of cervical adenitis the 
tonsils should be removed as the first 
procedure. If the glands are not 
broken down, and an operation on 
them has to be performed, then the 
tonsil should be removed at the same 
time. Removal seems to be followed 
by no deleterious effects, while the 
tonsil may afford entrance for rheu¬ 
matic infection. Richards (Boston 
Med. and Surg. Jour., Jan. 7, 1915). 

As shown below prudence is necessary 
in the removal of diseased tonsils, lest 
general infection result if tubercle bacilli 
are present. Pottenger deems it necessary 
to emphasize the importance of prudence 
in this connection. Our own practice is to 
give the iodides internally and to treat the 
tonsils by means of the curette, the phenol- 
ated iodo-tannin glycerite (see vol. vii, 
page 73) and galvano-cautery if necessary 
to close the crypts, removing the tonsils 


only if necessary after these procedures 
have greatly reduced or eliminated the 
danger of systemic infection. Editors. 

Senn held that early operative in¬ 
terference is as necessary in the treat¬ 
ment of tubercular adenitis as in the 
treatment of malignant tumors, and 
holds out more encouragement, so far 
as a permanent cure is concerned. 
Tillniann argues that glandular tuber¬ 
culosis should be operated as soon as 
possible, in order to prevent general 
miliary tuberculosis by the passage of 
the bacilli into the system. 

The treatment by filiform drainage 
is simple and easily carried out under 
local or no anesthesia, and results in 
a cure, without any noticeable scar¬ 
ring, in about 2 weeks. In small, 
superficial, closed, cold abscesses in 
which the overlying skin is not in¬ 
flamed, he passes a large needle com¬ 
pletely through the lesion, carries 2 
strands of horsehair through it, knots 
them to form a loop, passes through 
2 more strands perpendicular to the 
first 2 (crucial drainage), and applies 
a dry zinc peroxide dressing. In 
large, deep abscesses of the same 
kind he makes a narrow, stab in¬ 
cision, explores the abscess cavity 
and its pockets, with a probe or fine 
grooved director, and passes horse¬ 
hair from the central incision through 
the two poles and the various pock¬ 
ets of the abscess (radial drainage). 
Where' the skin is inflamed it can be 
kept from ulcerating by inserting 
crucial horsehair strands through the 
abscess from the sound skin; if per¬ 
foration of the skin does take place 
it soon closes under a dry zinc per¬ 
oxide dressing. Chaput (Paris med., 
Apr. 22, 1916). 

Rapid and complete healing is al¬ 
ways realized in the writer’s cases 
after excision of tuberculous glands 
in the neck, owing to his routine pro¬ 
cedure of suturing immediately with¬ 
out draining. In more than half of 
his 63 cases the gland burst and pus 
inundated the field, but his assump¬ 
tion that the pus in such cases is 


364 


ADENITIS (WITHERSTINE). 


sterile was always confirmed by the 
healing by primary intention. Du- 
fourmentel (Presse med., Dec. 5, 
1918). 

After incision, closure should be 
performed. The wound should be 
drained. The operator should not only 
feel, but see, every gland he removes. 
In cervical adenitis an S-shaped in¬ 
cision gives more room and a better 
cicatrix. 

In other regions the incision should 
be made so as to bring its axis parallel 



Sigrmoid incision lor the removal of cervical 
glands. (Senn.) 


with the cutaneous folds. Local recur¬ 
rence should be treated in the same 
way. Three or four operations in as 
many years have been performed by 
Senn on the same patient, with final 
successful result. 

Mitchell, of Johns Hopkins Hospital, 
uses a T-shaped incision when making 
a radical operation for removing all the 
glands and surrounding fat. The long 
arm of this incision is made to curve 
forward over the sternomastoid muscle 
and starting from the mastoid process 
joins the short arm along the clavicle, 
the dissection being carried from below 
upward and outward from the mesial 
line, the external jugular vein being 
tied with two ligatures and divided be¬ 


tween them. The omohyoid muscle is 
then divided, and by using it as a 
retractor the internal jugular vein is 
exposed and the sternomastoid muscles 
pulled aside. In dissecting out the 
mass of glands the greatest difficulty is 
experienced with the chain connecting 
the anterior and posterior triangles 
behind the sternomastoid muscle, as the 
spinal accessory nerve passes through 
the mass and is generally very adherent. 
It is only when there is very extensive 
mischief that it becomes necessary to 
divide the sternomastoid muscle or 
spinal accessory nerve, or even to tie 
and divide the internal jugular vein, 
and these steps should only be resorted 
to when the advantages of free ex¬ 
posure outweigh other considerations. 
The wound is closed with a subcu¬ 
taneous silver suture and drained at its 
most dependent part. The resulting 
scar is usually slight. 

When many glands are involved and 
suppuration has occurred, or when peri¬ 
adenitis is present, excision is not to be 
recommended, as extensive connective- 
tissue infiltration renders it impossible 
to remove all the infected tissue. 

Subcutaneous extirpation may be 
.resorted to, but the method allows of 
but imperfect evacuation of the glan¬ 
dular contents and is unsatisfactory. 

Drainage of the abscess is a measure 
which may be recommended for many 
reasons. A small incision is sufficient 
for all purposes, and there is practically 
no scar left. 

Mesenteric tuberculous glands should 
be removed if possible. They are usu¬ 
ally discernible as persistent movable 
tumors beneath the abdominal wall, 
with anorexia, loss of weight and 
strength, occasional fever, colicky pains, 
and possibly mucous in the stools with a 
tendency to diarrhea. 



ADENITIS (WITHERSTINE). 


365 


Less radical measures sometimes 
bring about a cure. A transformation 
of the tuberculous tissues into a scle¬ 
rotic mass may be obtained. A solution 
of chloride of zinc injected about the 
tuberculous foci excites a growth of 
new fibrous tissue, which encapsulates 
the diseased portion. 

Solutions of iodoform and ether 
(iodoform, 1 part; ether, 5 parts; dis¬ 
tilled water, 5 parts. Injection not to 
be repeated while iodoform is being 
excreted in the urine), after Verneuil, 
in cases where operative procedures are 
indicated, give a lasting cure, without a 
cicatrix. These injections seem to 
exert a beneficial action not only on 
the tuberculous glands treated, but also 
on those at a distance from the seat of 
the injection. Robin uses an injection, 
iodoform, 1 part; ether, 10 parts; oil 
of sweet almonds, 100 parts; creosote, 
2 parts. 

Camphor-naphthol has proved valu¬ 
able in some cases. It is prepared as 


follows:— 

R Betanaphthol, 

Camphor .aa 10 parts. 

Alcohol {60 per cent.) .40 parts. 


A few drops are to be injected, with 
antiseptic precautions, here and there 
throughout the mass of indurated 
glands, as suggested by Courtin, of 
Bordeaux. 

It is claimed in favor of camphor- 
naphthol that there is no danger of 
intoxication and that the treatment is 
almost painless. Menard and Calot, 
however, have reported cases of intoxi¬ 
cation following injection of camphor- 
naphthol into abscess cavities. The 
patient suffered from frequent, rapid 
pulse, loss of consciousness, and epilep¬ 
tiform attacks. The quantity of the 
drug injected was about 6 drams. This 
patient recovered. In another case, 8 


years of age, 1^ ounces of the solution 
were injected. In the third case, aged 
12, 5 drams. In the last 2 cases life 
was saved by freely opening the cavity 
and washing it out on the first appear¬ 
ance of toxic symptoms. 

Interstitial injections, of iodine, fre¬ 
quently recommended, usually fail or 
cause suppuration, owing to the fact 
that the tincture of iodine is employed. 
Metallic iodine, however, gives good 
results; the abscess is filled with the 
crystalline iodine, 8 or 10 applications 
usually insuring a cure. 

Exposure to sunlight constitutes 
the most eligible conservative treat¬ 
ment, being preferable because it acts 
upon the entire body while taking the 
patient away from his ordinary mode 
of life. Iselin (Correspondenzbl. f. 
schweizer Aerzte; Wiener klin. 
Woch., Nu. 45, 1912). 

Barjou, of Lyons, commends the use 
of the X-ray in the treatment of tuber¬ 
cular adenitis. The principal effect of 
this treatment is upon the general in¬ 
filtration which so often accompanies 
scrofula, uniting the lymph-glands in a 
solid mass. The glands become sep¬ 
arated soon after beginning the appli¬ 
cations, and later disappear. If there 
is any tendency to softening, the rays 
hasten this, so that the abscess may be 
opened earlier. The rays continue to 
have a good effect upon the suppurat¬ 
ing tissues. Untoward effects or tend¬ 
ency to cause metastasis are rarely 
noted. The late C. L. Leonard deemed 
it the most effective method for the 
treatment of tuberculous adenitis in all 
its varieties. It affords also the best 
cosmetic, as well as permanent, results. 
Much evidence to this effect was ad¬ 
duced in the foregoing pages. 

Cases of tuberculous adenitis were 
formerly given X-ray treatment to 
avoid unsightly scars, but to-day it is 




366 


ADENOID VEGETATIONS (KNIGHT AND CARISS). 


used because operation is followed by 
frequent recurrence. The X-ray treat¬ 
ment is preferable when the glands 
are scattered or broken down. Boggs 
(N. Y. Med. Jour., May 27, 1916). 

Twenty cases of tuberculous adeni¬ 
tis treated successfully with radium. 
The nodes at all stages disappeared, 
leaving no scar unless a sinus had 
been present at the beginning of the 
treatment. Ulceration did not occur 
in any case. Fifteen milligrams of 
radium bromide spread over an ap¬ 
plicator 114 inches in diameter, 
screened by 1 millimeter of silver, 
was strapped over the area to be 
treated for 10 hours. Two applica¬ 
tions a week were usually employed. 
After a week or 10 days the swelling 
began to grow smaller and at the end 
of a few weeks nothing but fibrous 
nodules were left. E. S. Molyneux 
Brit. Med. Jour., Nov. 29, 1919). 

Koch’s tuberculin and the simul¬ 
taneous use of the Bier method have 
been used 'with success in tuberculous 
adenitis. 

At the Westfield State Sanatorium, 
Mass., patients having no more than 
1 degree of temperature, and having 
no other signs of active pulmonary 
disease, are given tuberculin treat¬ 
ment, the bacillin-emulsion being 
used. The initial dose is one-mil¬ 
lionth of a milligram and the course 
of treatment extends over a period 
of about 6 months until the maxi¬ 
mum of 10 milligrams is reached. 
The glands decrease perceptibly in 
size and the area of dullness over the 
hilus becomes less pronounced. Sur¬ 
gical interference is necessary to re¬ 
move only such glands as have be¬ 
come caseous or fibroid. H. D. Chad¬ 
wick (Boston Med. and Surg. Jour., 
Jan. 7, 1915). 

Of 40 cases of surgical tuberculosis 
treated by the writer with tuberculin, 
19 had glandular disease of the cer¬ 
vical group, 1 case showing also in¬ 
volvement of the axillary group. Of 
the joint cases, the hip was involved 
in 6. In 4 cases the vertebrae were 
affected. Of the 19 cases, 12 were 


discharged as well, 6 improved, and 1 
unimproved when last seen. Sieber 
(Amer. Jour. Med. Sci., Sept., 1917). 

C. Sumner Witiierstine, 

Philadelphia. 

ADENOID VEGETATIONS.— 
DEFINITION. —A definition of ade¬ 
noid vegetations, or adenoids, must he 
somewhat elastic. The name tonsil is 
often applied, and we hear pharyngeal 
tonsil, third tonsil, Luschka’s tonsil, 
or bursa, used indiscriminately. It 
would be well to restrict the term 
tonsil to the lymphoid aggregation 
between the pillars of the fauces, 
where it was first employed. The 
word adenoid seems to have been pro¬ 
posed nearly two thousand years ago 
(Wright, “The Nose and Throat in 
the History of Medicine”), is there¬ 
fore sanctified by time and usage, and 
will doubtless be permanently re¬ 
tained. 

Lymphoid tissue is a normal con¬ 
stituent of mucous membranes, but the 
question: When does it become patho¬ 
logical? is not easy to answer. On the 
one hand we are told that it is abnormal 
“when visible to the naked eye,” and 
on the other “when it causes subjective 
symptoms.” Many insignificant hyper- 
plasiee cause a good deal of disturb¬ 
ance, and on the contrary in a stolid, 
phlegmatic child or in a pharynx of 
large dimensions very considerable 
hypertrophies often seem to interfere 
but little with comfort or health. An 
accurate definition is desirable, but in 
view of the fact that lymphoid tissue 
is a recognized avenue for invasion of 
the system by pathogenic germs it is 
most important to determine in what 
condition of this tissue, healthy or 
diseased, the process of invasion is 
favored. Clinically it is clear that, 
when diseased, it is no longer capable 


ADENOID VEGETATIONS (KNIGHT AND CARISS). 


367 


of performing its physiological function 
and is a detriment to health quite apart 
from effects due merely to mechanical 
obstruction. ' The general symptoms 
present can hardly be explained on the 
latter ground alone. A species of 
toxemia must be also concerned. Dis¬ 
tended crypts provide an excellent bed 
for the cultivation of germs, which find 
ready access to the circulation in the 
absence of effective resistance. Lym¬ 
phoid tissue may be a portal of entry 
without itself showing marked patho¬ 
logical change, while it is probable that 
a dense fibrous adenoid, as met with in 
older subjects, may offer a firm barrier 
to bacterial assaults. 

In keeping with Harris and others, 
the writer looks upon adenoids as de¬ 
fensive structures in prolonged ex¬ 
posure to pathogenic agents. S. G. 
Vicente (Rev. de Med. y. Cir. Pract., 
July 14, 1915). 

The writer lays stress on the close 
relationship between the nasopharyn¬ 
geal glandular structures (adenoids, 
etc.) and the pituitary body. Not 
only are the functions of the latter 
morbidly influenced, but the results 
of adenotomy or Other local treat¬ 
ment of these pharyngeal tissues— 
rapid growth and improved nutrition, 
relief of aprosexia and morbid som¬ 
nolence, etc.—indicate to what ex¬ 
tent the pharyngeal tonsil and the 
pituitary system are related. The 
cases of retarded growth relieved by 
adenotomy suggest, moreover, that 
adenoids inhibit the nutritional or 
developmental function of the pituit¬ 
ary system which we have come to 
understand as necessary for normal 
development. In a former article 
the author pointed out that the “ade¬ 
noid” region was the part of the 
nasopharynx most assailable by in¬ 
fection, and that the angle of this 
region was the most vulnerable spot 
in the whole body. W. Sohier Bryant 
(Amer. Jour. Med. Sci., July, 1914; 
Med. Rec., Sept. 9, 1916). 


In certain adenoid subjects a psy¬ 
chic syndrome may be observed, 
especially in adolescence, which con¬ 
sists in a marked deficiency in mem¬ 
ory, somnolence or insomnia, lack of 
power to fix the attention, and in in¬ 
tellectual weakness. This syndrome 
may even be observed in various dis¬ 
eased conditions of the nasopharynx 
and sphenoid regions, especially 
tumors. It is probably of hypophy¬ 
seal origin. The writers report the 
details of 3 cases observed in sol¬ 
dier , having a history of adenoids 
which had not been treated and rem¬ 
nants of which still persisted. The 
syndrome was marked in all 3, along 
with very manifest feminism. Citelli 
and Caliceti (Policlinico, xxv, sez. 
prat., 245, 1918). 

SYMPTOMS AND DIAGNOSIS. 

—It is not safe to rely upon the so- 
called “adenoid facies” as a diagnostic 
sign. A very similar appearance is 
sometimes seen in a subject of intra¬ 
nasal obstruction, while the postnasal 
space is quite free. A typical case of 
adenoid hypertrophy in the vault of the 
pharynx usually wears a dull, listless 
expression. The nostrils are narrow 
and pinched; tlie bridge of the nose by 
contrast seems widened. The upper lip 
is retracted, exposing the teeth of the 
upper jaw, which project and overlap 
those of the lower. The upper jaw is 
compressed laterally, so that the roof 
of the mouth is converted into a Gothic 
or V-shaped arch. Deflection of the 
nasal septum may be a result. The 
nasolabial folds are effaced, and the 
transverse vein at the root of the 
nose is unusually conspicuous (Scanes 
Spicer). The child has a pasty, sallow 
complexion, and the cervical glands are 
prominent. The nutrition of a nursing 
infant suffers in consequence of fre¬ 
quent interruptions due to need of get¬ 
ting air through the mouth. For a 
similar reason older children “bolt” 


368 


ADENOID VEGETATIONS (KNIGHT AND CARISS). 


their food, which being defectively in¬ 
salivated causes gastric derangement. 
The latter is further aggravated by 
catarrhal secretion, always in excess 
in these cases, finding its way into 
the stomach. Loss of appetite and 
malassimilation are natural sequels. 
In severe cases deformity of the 
chest, pigeon-breast (Dupuytren), re¬ 
sults from the bad constitutional state, 
the labored breathing, or from both 
combined. The mental dullness shown 
by these children is referred to inter¬ 
ference with the lymphatic drainage of 
the brain and to impaired hearing. 

An investigation of the occurrence 
of adenoids in three London elemen¬ 
tary schools, with an attendance of 
2315, showed that, on the average, 
about 37 per cent, of the children in 
elementary schools have adenoids, 
and that between 72 and 76 per cent, 
of these have enlarged tonsils as well. 
On the average, 31.2 per cent, of ade¬ 
noid cases are mouth-breathers, com¬ 
plete or partial, and hypertrophy 
of the faucial tonsils may give rise 
to mouth-breathing in the absence of 
adenoids. Sex appears to have no in¬ 
fluence upon the incidence of ade¬ 
noids. Adenoids are more common 
about the age of 8 years, and are next 
most frequent at about 12 years. True 
aprosexia is often confused with ap¬ 
parent dullness, due to defective hear¬ 
ing, and it occurs in only about 4.7 
per cent, of adenoid cases, is more fre¬ 
quent in girls, and, when present, is 
associated with a marked degree of 
adenoids. Macleod Yearsley (Brit. 
Jour. Child. Dis., Feb., Mar., 1910). 

Gritting of the teeth at night was 
noted in 34.4 per cent, of a series of 
500 cases of adenoids by the writer, 
and is believed by him of diagnostic 
value. Benjamins (Nederlandsch. 
Tijdschr. v. Geneesk, July 17, 1915). 

“Growing pains” are due to ade¬ 
noids in fidgety children with con¬ 
stant slight fever, slight cervical 
glandular enlargements, and a muf¬ 
fled first heart sound; great improve¬ 


ment follows adenoidectomy in these 
cases. H. O. Butler (Lancet, June 
26, 1915). 

The term aprosexia has been given to 
lack of ability to concentrate (Guye). 
Mouth-breathing is a source of much 
discomfort and even danger. The 
membranes of the whole respiratory 
tract sufifer from inhalation of improp¬ 
erly prepared air. 

Snuffling and noisy breathing by day 
and snoring at night are often distress¬ 
ing. Sleep is much disturbed thereby 
as well as by bad dreams, “night ter¬ 
rors” {pavor nocturnus) resulting from 
deranged cerebral circulation. The ef¬ 
fect upon the voice is characteristic. 
Its non-resonant, “dead” quality always 
suggests adenoids, at least in young sub¬ 
jects. The ability to precisely locate an 
obstruction from the sound of the 
voice, claimed by some, seems to be 
hardly warranted. In addition to 
special difficulty with the nasal con¬ 
sonants speech in general is thick and 
unpleasing. Actual stammering and 
stuttering have been ascribed to ade¬ 
noids, and a long list of reflex neuroses 
affecting the eyes, the ears, and more 
remote organs has been compiled. 
Among them may be mentioned laryn¬ 
geal spasm, hiccough, asthma, hernia, 
prolapse of the rectum, nocturnal 
enuresis, chorea, and epilepsy, some of 
which no doubt have their origin in the 
imagination of the observer. The rela¬ 
tion of laryngeal neoplasms to adenoids 
is a question of much interest. Even if 
we decline to accept a theory of “ver¬ 
rucous diathesis,” or special predisposi¬ 
tion to neoplastic development, it is 
reasonable to assume that habitual 
mouth-breathing must irritate the laryn¬ 
geal mucosa. It has also been sug¬ 
gested that secretions find their way 
from above into the vestibule of the 


ADENOID VEGETATIONS (KNIGHT AND CARISS). 


369 


larynx, and, again, that the extraordi¬ 
nary labor imposed upon the larynx 
during phonatign under these circum¬ 
stances favors the formation of new 
growths. 

Many excellent observers maintain, 
however, that neoplasms of the larynx 
are not especially common in adenoid 
cases. Frequent attacks of earache, 


In a large number of school chil¬ 
dren who suffered with blurring vis¬ 
ion and fatigue on reading, the author 
found nasopharyngeal hypertrophy to 
be the real cause of the symptoms. 
W. M. Killen (Brit. Med. Jour., Sept. 
25, 1909). 

The writer observed a child with 
mild bilateral exophthalmos, relieved 
by adenoidectomy. W. C. Posey 
(Pa. Med. Jour., July, 1912). 


Posterior rhinoscopic view. 


(After Grunwald.) 



of nosebleed, and a tendency to catch 
cold, are generally included in the list 
of symptoms. Headache and asthe¬ 
nopia are complained of, the senses 
of smell and of taste are impaired, 
and frequently an ichorous discharge 
excoriates the nostrils and upper lip. 
Attacks of petit mal in a child may 
also be due to adenoids. 

Impairment of hearing, chronic 
otorrhea, profuse nasal discharge sug¬ 
gesting sinusitis and sinusitis are fre¬ 
quently associated conditions. 

1- 


The picture in the rhinoscopic mirror 
is unmistakable. Lobulated or fissured 
masses of various sizes are seen hang¬ 
ing from the vault of the pharynx, 
obscuring the arches of the choanse, 
and often filling the fossae of Rosen- 
miiller and covering the orifices of the 
Eustachian tubes. They have been 
likened in appearance to a “cock’s 
comb” (Czermak, 1860), and they are 
spoken of by Voltolini (1865) as 
“stalactite-like growths,” a term adopted 
by Morell Mackenzie. They are often 

•24 . 


ADENOID VEGETATIONS (KNIGHT AND CARISS). 


370 

visible by anterior rhinoscopy when 
the intranasal structures have been 
shrunken by atrophy or retracted by 
cocaine. Sometimes the vegetations 
are distributed down the posterior 
wall of the pharynx, below the 
plane of the velum, or they may push 
forward into the nasal chambers. The 
view may be masked by viscid or in¬ 
spissated secretion, and, being fore¬ 
shortened in the mirror, does not give 
an adequate idea of the volume of the 
growth. In some cases, generally in 


Adenoids seen through anterior nares. 

(After Griinwald.) 

older subjects, the mass is more uni¬ 
form and cushion-like in appearance, 
or is bilobed, being divided by an 
anteroposterior median furrow {reces- 
sus pharyngeus medius), and is less 
vascular looking. In adults remnants 
of adenoids are often seen in the form 
of bands between the Eustachian 
cushion and the pharyngeal wall, which 
doubtless bear some relation to various 
subjective aural disturbances. 

Applications of cocaine and the use 
of a palate retractor are to be recom¬ 
mended only in older children and 
when a rhinoscopic examination is 
imperative. By the exercise of tact and 
patience it is often possible to get a 
view, even in a very unpromising case. 


In some it is out of the question and 
the only resource is a digital examina¬ 
tion. The process is disagreeable to the 
patient and dangerous for the examiner 
in children, unless one’s finger is pro¬ 
tected in some way. A finger shield of 
metal or rubber may be used, or a 
mouth-gag may be applied. Better 
still, the child being firmly held by an 
assistant, the examiner standing on the 
left presses the right cheek of the 
patient between the separated jaws with 
his right middle finger while he quickly 
passes his left forefinger into the open 
mouth and up behind the velum. The 
mouth cannot be closed and thus -the 
finger is safe. 

The anatomical landmarks to be 
sought are the posterior margin of the 
vomer in the middle line and the Eu¬ 
stachian eminences at the sides. A 
novice might mistake a prominent 
Eustachian cushion, a papillated pos¬ 
terior end of an inferior turbinate, or 
even the contracted velum (F. H. 
Hooper) for an adenoid mass, but the 
last is higher in the fornix of the 
pharynx and more posterior and has 
a distinctly lobulated, elastic, and pulpy 
feeling, compared to that of a bunch of 
earthworms. On withdrawal the fin¬ 
ger is smeared with blood, which is not 
the case when a healthy pharynx is ex¬ 
plored, unless excessive force has been 
exercised. In those who object to the 
finger some idea of the extent and con¬ 
sistence of a postnasal growth may be 
gained by palpation with a stiff probe 
or the edge of a rhinoscopic mirror. 
In some cases a very beautiful view of 
the vault of the pharynx is given by the 
ingenious electric pharyngoscope de¬ 
vised by Hays. The end of the instru¬ 
ment having been passed into the oro¬ 
pharynx the patient is instructed to 
close the lips and breathe quietly 






ADENOID VEGETATIONS (KNIGHT AND CARISS). 


371 


through the nose. The palatal muscles 
relax and permit the light to flood the 
cavity of the rhinopharynx. With a 
little patience and care a complete 
picture may be obtained, even in very 
sensitive throats. Nasal polypi, retro¬ 
pharyngeal abscesses, syphiloma, and 
neoplasms, benign or malignant, may 
occur in this region, but usually present 
features or give a history which serve 
to distinguish them. 

Benign nasopharyngeal polypi, stud¬ 
ied in 22 cases. They are usually uni¬ 
lateral and solitary, and have a peculiar 
pear-shaped form, the broad end lying 
in the nasopharynx, while the stalk ex¬ 
tends into the nose. They may attain 
considerable size, and are subject to in- 
flanmiatory changes which may end in 
partial or total gangrene. The treat¬ 
ment is very favorable, as they are 
easily laid hold of, and readily torn out 
on account of their slender stalk. In 
the majority of cases the polypi do not 
recur. 

There is usually a profuse dis¬ 
charge of serous fluid after the extrac¬ 
tion, and examination of the antrum 
shows a slight chronic inflammation. 
Choanal polypi originate within the 
antrum of Highmore, and are due to 
inflammation of the antral mucous 
membrane. Killian (Lancet, July 14, 
p. 81, 1906). 

It is hard to believe that a simple 
pendulous polypus of the nasopharynx 
could be mistaken for a bunch of ade¬ 
noids. Yet the risk is evidently present 
in the minds of some observers. In 
a paper by W. A. Wells (Laryngo¬ 
scope, July, 1911) the fact is noted 
that it is usually taken for granted 
that postnasal obstruction in a child 
under 15 years is due to adenoids. He 
describes 3 cases of fibrous polypus, 
which he makes the basis of a plea for 
intranasal removal with the cold-wire 
snare rather than by a “mutilating” 
external operation generally employed 
in growths of this kind. He enumer¬ 


ates three theories of etiology: (1) 
cranial, propounded by Nelaton; (2) 
choanal, that is, springing from the 
ethmoid, sphenoid, or vomeral region, 
and (3) sinusal, as adopted by Killian 
in the paper above quoted. While it 
is well to bear them in mind, fibrous 
polypi of the pharynx are so rare and 
their symptoms are so different from 
those of adenoids, except in the single 
feature of obstruction, that the chance 
of confusion is rather remote. 

Rugae or folds of thickened mucous 
membrane in the floor of the nose, and 
the so-called “lateral bands” of red and 
thickened membrane on the walls of 
the phai*ynx behind the posterior pillars 
(pharyngitis lateralis hypertropica) 
are regarded by some as pathogno¬ 
monic, but each is often found without 
adenoids. Fluid injected into one nos¬ 
tril is expected to escape by the other 
if the nasopharynx is free; by the 
mouth if adenoids are present (Semon, 
quoted by Schech). A similar test with 
oil spray is regarded as “almost abso¬ 
lutely diagnostic” (Bosworth). Each 
of these experiments must be invali¬ 
dated by a unilateral nasal stenosis and 
should not be relied upon. 

Adenoids may exist without enlarged 
faucial tonsils: the reverse is seldom 
true. Hence it is important to examine 
the pharyngeal vault in all who mani¬ 
fest the latter condition. The occur¬ 
rence of adenoids, as well as of tur¬ 
binate hypertrophy, in victims of cleft 
palate has often been remarked, 
whether as an effort of nature to stop 
the gap or as a consequence of the 
same diathesis that caused the palatal 
deformity is hard to decide. Such cases 
afford unusual opportunity for study of 
these anomalies. 

ETIOLOGY. —A constitutional state 
allied to struma, termed lymphatism 


372 


ADENOID VEGETATIONS (KNIGHT AND CARISS). 


(Potain), predisposes to lymphoid hy¬ 
perplasia. From observation of 1995 
cases Sendziak concludes that “scrof¬ 
ula” plays an important part in 
etiology, a view shared by Lennox 
Browne. The exanthemata, syphilis, 
tuberculosis, are similarly accused. 
Poor sanitation, bad hygiene, and im¬ 
proper diet are undoubted factors, yet 
not infrequently cases occur in which 
none of the foregoing elements is 
concerned and we are at a loss to dis¬ 
cover the cause of the condition. 

The importance of nasal stenosis, 
resulting perhaps from some injury in 
early life, is generally admitted. Be- 
. hind an obstruction the air is so rare¬ 
fied on inspiration that congestion of 
the mucous membrane results with 
consequent tendency to hyperplasia. 
The bearing of this fact with refer¬ 
ence to treatment should be appreci¬ 
ated. The habitual breathing of im¬ 
pure air, or of air too hot or dry, often 
prevailing in our homes and sleeping 
rooms, no doubt has a bad efifect on 
the mucous membranes. The same is 
true of certain occupations that in¬ 
volve the inhalation of irritating va¬ 
pors or floating matter in the air. 
The condition occurs with equal fre¬ 
quency in the two sexes. It seems 
reasonable to admit an inherited pro¬ 
clivity. Those who deny the exist¬ 
ence of heredity find it difficult to ex¬ 
plain the exhibition of almost identical 
local conditions in several successive 
generations. The effect of a rigorous 
climate is not necessarily bad, but ex¬ 
tremes and sudden changes of temper¬ 
ature and humidity are no doubt 
harmful. 

Adenoid growths are essentially a 
(disease of early life, of the formative 
period, when the lymphoid tissues are 
especially active. A few congenital 


cases are on record. Among 437 chil¬ 
dren in the first three years of life 
examined by W. F. Chappell not a 
single example of lymphoid hyper¬ 
trophy under the age of three months 
was found. 

R. G. Freeman has rightly criticized the 
neglect of adenoids in early infancy, as 
they interfere with the proper develop¬ 
ment of the child by reflex action, by the 
irritation they produce and the obstruc¬ 
tion they cause. The postnasal pharynx 
at birth is a space only one-quarter inch 
high by one-third inch wide, so that a very 
slight adenoid hypertrophy at this period 
will cause obstruction. At the end of the 
first year it is nearly doubled in size. . It 
often produces symptoms in the first days 
of life, and the mistake is sometimes made 
of diagnosing specific disease. The snuf¬ 
fles are specially marked while the child 
is nursing and result from an adenoid 
which produces irritation, and, if large 
enough to obstruct the pharynx, there is 
mouth-breathing, 

A survey of 1064 operations for the 
complete removal of tonsils and aden¬ 
oids caused the writer to wonder 
whether all these operations are 
really necessary. The removal of 
adenoids in the so-called idiopathic 
asthma of the nervous, wheezy child 
has no beneficial effect, and most of 
these children have no adenoid 
growth. Idiopathic asthma must not 
be confused with the intermittent 
suffocative attacks during sleep, which 
are due to adenoids, and are cured 
by the removal of the growth. A 
large number of children have attacks 
of earache and deafness during colds, 
with retraction of the drums, which 
frequently suppurate; and if such a 
case is allowed to continue without 
operation, the deafness or dullness of 
hearing becomes permanent, and is 
beyond cure. The affection of the 
ears makes operation imperative. 
The writer has carefully examined a 
large number of children 6 months 
or more after operation, and has en¬ 
deavored to follow up cases, and has 
not observed any deleterious effects 


ADENOID VEGETATIONS (KNIGHT AND CARISS). 


373 


or disadvantages following removal 
of tonsils and adenoids. He has not 
obtained any evidence to indicate that 
the removal of the tonsils predisposes 
these children to diphtheria, scarlet 
fever, or other acute infections, but 
has seen several cases of unhealthy 
spongy tonsils yielding cultures of 
the Klebs-Loeffler bacillus weeks af¬ 
ter the quarantine period had elapsed. 
E. D. D. Davis (Brit. Med. Jour., 
Jan. 26, 1918). 

Numerous statistics are available 
shovv^ing* a preponderance of evidence 
that removal of diseased adenoids 
and tonsils decidedly lessens the sus¬ 
ceptibility to the contraction of the 
acute exanthematous diseases. 

Rare instances have been noted in 
the aged, but the tendency is toward 
atrophy after puberty. Several cases 
in elderly people have been observed 
by Br^^son Delavan, who holds the 
belief that the condition may develop 
in middle life and is not necessarily a 
legacy from childhood. One was dis¬ 
covered by J. Solis-Cohen in a woman 
of 70, and a number of authentic cases 
after the age of 60 have been reported 
(P. G. Frank), but at this time of life 
a malignant element is always to be 
suspected. The curious observation 
has been made by Gelle that these 
structures sometimes show renewed 
activity at the menopause. 

The bacteriology of adenoid tissue 
is very similar to that of the tonsils, 
among the infective organisms being 
staphylococci, pneumococci, strepto¬ 
cocci and at times the Klebs-Loeffler 
bacilli and the tubercle bacilli. A sur¬ 
prising number of cases show the 
streptococcus hemolyticus and strep¬ 
tococcus viridans. 

PATHOLOGY. —Lymphoid cells 
embedded in a reticulum of connective 
tissue containing small blood-vessels 
and nerves, the retiform adenoid tis¬ 


sue of His, and enclosed in a mucous 
membrane covered by columnar cilia¬ 
ted epithelium, constitute adenoid 
vegetations. The relative proportion 
of these elements varies with the age 
of the patient, the duration of the dis¬ 
ease, and the frequency and intensity 
of acute inflammatory attacks, to 
which this tissue is very liable. In 
young subjects cells predominate and 
the tissue is soft, friable, and vascular; 
in older ones connective tissue is in 
excess and the mass is more dense 
and hard. 

As' a matter of clinical convenience 
adenoids are sometimes divided into 
soft and hard, which are, of course, 
merely grades of the same patholog¬ 
ical process. In very young children, 
also, a temporary intumescence takes 
place in consequence of gastrointesti¬ 
nal disturbance or other cause, when 
many of the subjective symptoms of 
adenoids are presented. This condi¬ 
tion, naturally, calls for different 
treatment than an organized hyper¬ 
plasia. Morbid changes are not con¬ 
fined to the epipharynx, but involve 
adjacent lymphoid structures. Cystic 
transformation and other disorders of 
the pharyngeal bursa have been par¬ 
ticularly described by Tornwaldt. A 
cyst of the bursa may reach extreme 
dimensions and occasionally small 
cysts are met with in the adenoid 
tissue, but the importance of these 
conditions has been somewhat ex¬ 
aggerated. The idea once expressed 
by Woakes that adenoid vegetations 
are papillomatous is not sustained. 

PROGNOSIS. —Under present-day 
methods of attacking the disease the 
prognosis is good, both as to arrest of 
the morbid process and relief of asso¬ 
ciated symptoms. Only in case the con¬ 
dition has been extreme in degree or 


374 


ADENOID VEGETATIONS (KNIGHT AND CARISS). 


duration organic changes may have been 
established, for example in the ears, 
which are irremediable. Chronic otor¬ 
rhea due to adenoids cannot be cured 
while the latter are allowed to persist. 
Likewise impaired hearing and tinnitus 
due to occlusion of the Eustachian tube 
from pressure or congestion must be 
reached through removal of an adenoid 
mass. Recurrence of adenoids may take 
place in certain cases of pronounced 
lymphatism (status lymphaticus), in 
which predisposing factors cannot be 
wholly eliminated, or when an opera¬ 
tion for removal has been done very 
early in life. The suspicion remains, 
however, that some alleged relapses are 
jeally examples of incomplete removal. 
These partial operations are explained 
in a measure by A. A. Bliss on the 
ground that the lymphoid tissue pene¬ 
trates the fissures of the vomerosphe- 
noidal articulation {canales basis vomeri 
of Harrison Allen), where it is more or 
less inaccessible. Extreme vascularity 
of the region and the fact that the 
adenoid is often made up of separate 
and distinct bundles also contribute to 
the possibility of apparent recurrence, 
which is really a growth of tissue that 
has evaded the knife. 

It is safe to say that no operation in 
the upper air tract confers more grati¬ 
fying and positive benefits than an 
adenectomy properly done. There has 
been much controversy as to the thor¬ 
oughness with which morbid tissue 
should be removed, one side advocating 
extirpation of every vestige and the 
other averring that such a course is 
ultraradical. When we reflect upon the 
wide distribution of lymphoid tissue in 
the so-called ring of Waldeyer, or 
lymphoid triangle, the conclusion is 
forced upon us that absolute eradica¬ 
tion is impracticable, even if desired. 


What we accomplish in a given case is 
extraction of the most salient and dis¬ 
eased portions: the consequent im¬ 
provement in air supply and in other 
respects enables nature to do the rest. 
This statement is not to be taken as a 
defense of superficial operating, or as 
a suggestion that we may trust nature 
to supply defects involved in our own 
negligence. Postoperative shrinkage of 
any considerable remnants is not to 
be expected, these fragments showing 
rather some apparently compensatory 
hypertrophy, yet there are limits of 
safety beyond which we may not pass 
and anatomical conditions which are 
insuperable. Certainly erasion of the 
mucous membrane through its whole 
thickness, so as to replace glandular 
tissue by scar tissue, is inadvisable. 

Adenoid tissue is present in the 
vault of the pharynx in 1 out of 
every 4 recruits. It should be re¬ 
corded in the physical examination 
so that due weight may be given to 
it as a factor in producing defec¬ 
tive hearing when cases of this sort 
come up for discharge for disability 
or pension. All large adenoids should 
be excised on entry into the service, 
and smaller masses if associated with 
pathological changes in the middle 
ears. Refusal to consent to opera¬ 
tion should disqualify applicants for 
enlistment in the artillery branch of 
the service or transfer to that branch. 
Every 2 out of 3 recruits who have 
adenoids have visible changes in the 
middle ears. Fifty per cent, of the 
cases who do not have adenoids, but 
who do have hypertrophied tonsils, 
have changes in the middle ears. 
Changes in the middle ears without 
th presence of either adenoid or 
tonsillar hypertrophy are unusual, 
and occur in only 1 case out of 12, 
and in the case in which it occurs it 
is usually associated with hypertro¬ 
phic rhinitis. In other words, in 11 
cases out of 12 which show changes 
in the middle ears, adenoid or ton- 


ADENOID VEGETATIONS (KNIGHT AND CARlSS). 


375 


sillar hypertrophy will be found. One 
out of every 3 cases with adenoids 
will also have hypertrophied tonsils. 
Two out of every 3 cases with hyper¬ 
trophied tonsils will also have ade¬ 
noids. Recruits with marked hyper¬ 
trophy of the tonsils should have 
the glands excised, whether they 
have had repeated attacks of acute 
tonsillitis or not. Adenoids do not 
undergo spontaneous atrophy in 
young adults. Le Wald (Military 
Surgeon, May, 1910). 

In a small proportion of cases breath¬ 
ing by the natural channels is not at 
once resumed. This is due simply to 
the habit of mouth-breathing, or to im¬ 
perfect development of the air tract 
from prolonged disuse. In the former 
case the habit is soon corrected by some 
device for binding up the chin and 
keeping the mouth closed during sleep. 
In the latter the difficulty is greater and 
it may be a long time before the normal 
respiratory current is restored. These 
cases, fortunately rare, are most dis¬ 
appointing to operator and parents and 
yield, if at all, only to careful attention 
to hygiene and to measures tending to 
promote development. The co-opera¬ 
tion of the dentist is enlisted for cor¬ 
rection of the oral deformity, widening 
the dental arch and thus depressing the 
floor of the nose and increasing the 
diameters of the nasal passages. It 
is best not to delay this beyond the 
sixth or seventh year (E. A. Bogue), 
although surprising results may be 
achieved much later. 

In some cases mouth breathing de¬ 
velops without any malocclusion or 
nasal obstruction, the mouth simply 
being involuntarily relaxed. This is 
corrected by forced nasal breathing 
at night through the use of lip and 
chin bandages. Skilful massage of 
the relaxed tissues is also helpful. 
O. W. White (Jour. Amer. Med. 
Assoc., Sept. 25, 1915). 


Two other causes of continued diffi¬ 
culty in breathing after . adenectomy 
have been described: one is extraor¬ 
dinary prominence of the bodies of 
the cervical vertebrae (J. E. Newcomb), 
and the other is a paresis of the sus¬ 
pensory apparatus of the hyoid bone 
and the tongue, so that, when the mus¬ 
cles are relaxed in sleep, the tongue 
falls back and occludes the glottis 
(Harrison Allen). 

In the experience of Payson Clark 
mouth-breathing persisted in 35 out of 
75 cases whose subsequent history 
could be learned. Over 500 others 
were not traced and it is fair to assume 
that the above percentage might be 
greatly reduced. 

Faulty habits of speech are to be re¬ 
formed by careful exercises under com¬ 
petent supervision. The palatal muscles 
having been long curbed in their action 
need to be properly educated. 

TREATMENT. — Until Wilhelm 
Meyer, in 1868, gave to the world the 
results of his careful studies, but little 
had been done in diagnosis or treatment 
of adenoids. A few scattered refer¬ 
ences are found in literature many 
years before his day, and the valuable 
researches of Luschka and others in the 
anatomy of this region are well known, 
but no serious attempts were made to 
remove from the postnasal region cer¬ 
tain obstructions, and their exact nature 
was not fully understood until Meyer 
began his investigations. 

In the hope of escaping surgery 
various local astringent applications and 
methods of treatment have been ad¬ 
vised, all of which are more or less 
futile, except in the vascular or 
“cyanotic” adenoid of some writers. 
In these cases instillations of adrena¬ 
lin chloride, 1 to 5000, followed by fine 
sprays or vapors of mentholized albo- 


376 


ADENOID VEGETATIONS (KNIGHT AND CARISS). 


lene are of service. Glycerite of tan¬ 
nin and other astringents can have 
little or no permanent effect while the 
underlying cause remains. Anemia, 
gastrointestinal derangements, or 
other disorders must be corrected by 
proper hygiene, diet, and general 
medication as indicated. 

Internal medication offers, but little. 
With anemic or chlorotic children one 
is often inclined to temporize and try 
to build up the system by means of 
iron and other tonics, but the speedy 
improvement in general condition 
following surgical intervention is con¬ 
clusive proof that the main cause 
of the constitutional depression lies 
in the local disorder, upon which 
medication alone has little or no 
effect. 

The internal and local use of iodine 
for its sorbefacient effect has not had 
success. The Bier suction hyperemia 
treatment, for which very temperate 
claims are made in hypertrophy of 
the faucial tonsils, does not seem to 
have been applied to adenoids. The 
tubes figured by Meyer-Schmieden 
for aspirating the nasal chambers and 
the sinuses would make but little im¬ 
pression in the postnasal space, al¬ 
though good results in atrophy of the 
nasopharynx are mentioned. 

At one time certain “breathing ex¬ 
ercises” were loudly vaunted as a cure 
for adenoids. The shallow character 
of respiration practised by most people 
and the health-giving value of deep 
breathing are generally comprehended 
in these days, especially in connection 
with the class of cases under consider¬ 
ation. Meyer appreciated the fact that 
a dense hyperplasia cannot be dissi¬ 
pated by breathing exercises, or by 
measures tending to promote the gen¬ 
eral health, or designed to exert a con¬ 


tractile effect upon the morbid 
growth. His early essays at removal 
•were made with a small ‘Ting knife” 
passed through the anterior naris and 
guided by a finger inserted behind the 
velum. It was soon found possible to 
operate more easily and expeditiously 
through the mouth, and in conse¬ 
quence today the instrument shops 
are flooded with forceps, guillotines, 
and curettes designed to facilitate this 
procedure. 

Adenoids present at birth, while 
never sufficiently large to endanger 
life, may cause obstructed nasal 
breathing, shown by restlessness, in¬ 
drawing of the diaphragm, and in¬ 
ability to suck. A few days after 
birth the infant begins to breathe 
with the mouth open, to snort and 
sniffle. Owing to the nasal obstruc¬ 
tion it swallows air while trying to 
suck, which makes it sick and gives 
it windy spasms. 

When removing adenoids under the 
age of 6 months a general anesthetic 
is neither required nor advisable. The 
infant is held in a sitting position by 
a nurse, a small curette is passed up 
behind the soft palate into the post 
nasal space and brought down with 
one sweep. It requires but a tiny 
pad of adenoids to cause symptoms, 
but in some cases one is surprised 
at the amount of adenoids removed. 
As a rule, very little bleeding takes 
place. The infant should be kept 
warm, and if there appears to be any 
shock, should be given a drop or 2 
of brandy in a little milk. It should 
not be fed for 3 hours before the 
operation, but can be given the breast 
or bottle 10 minutes or so after it. 
Hunter Tod (Pract., Nov., 1920). 

In adopting a plan of operation the 
principles of thoroughness, gentleness, 
and celerity are to be observed. By the 
first is meant not a clean sweep of all 
the soft parts down to the bone, but a 
removal of projecting tabs that can be 
detected by the examining finger. The 


ADENOID VEGETATIONS (KNIGHT AND CARISS). 


377 


second is insured by selection of instru¬ 
ments that include in their bite generous 
segments of tissue. Thus the need of 
frequent reintroductions is obviated and 
the parts are spared unnecessary vio¬ 
lence and contusion. Finally, while 
undue haste is to be avoided, it is well 
to abbreviate as much as possible the 
period of narcosis. We are prone to 
underestimate the importance of this 
detail. As a matter of fact, a large 
proportion of accidents, both immedi¬ 
ate and secondary, can be traced to ex¬ 
cessive crowding of the anesthetic at 
the hands of one who is not expert in 
its management. Important among 
these is pulmonary abscess. General 
anesthesia should always be in charge 
of one trained for the duty, who 
knows how to get satisfactory relax¬ 
ation with a minimum of anesthetic. 

The fatalities in a tonsil-adenoid 
operation may be due to: 1. Faulty 
administration of the anesthetic be¬ 
cause of: (o) failure to select the 
appropriate anesthetic; (b) lack of 
knowledge, so that a deep anesthesia 
is mistaken for a light one; (c) fail¬ 
ure to maintain a free air passage 
and to watch the respiration and cir¬ 
culation; (d) failure to regulate or 
change the anesthetic when circum¬ 
stances alter; (e) overdosing, abso¬ 
lutely or relatively. Of these causes, 
(a) and (c) are more common than 
(e). 2. Respiratory obstruction, due 

to the location of the operative field 
just above the air passage. 3. Shock. 
4, Hemorrhage. 

Status lymphaticus should be con¬ 
sidered as more of an idiosyncrasy; 
the author thinks many reported 
cases could have been otherwise ex¬ 
plained. As to treatment, the head 
should be lowered, the face sponged 
with cold water, the air passage 
cleared, either by swabbing, main¬ 
taining firm intermittent pressure on 
the back of the chest, by artificial 
respiration, or even tracheotomy. 
Finger pressure over the trachea and 


larynx through the skin is also sug¬ 
gested as a feasible means of express¬ 
ing blood clots. J. D. Mortimer 
(Pract, xcix, 482, 1917). 

Preparation of the Patient.—While 
adenectomy may not be properly con¬ 
sidered a major operation, yet it is by 
all means to be postponed in the pres¬ 
ence of any acute local disturbance, 
or of concurrent general disorder, or 
when an epidemic of any contagious 
disease is prevailing. The advice 
once given by Lennox Browne to op¬ 
erate during an attack of diphtheria, 
with a view of averting the necessity 
of a tracheotomy, is refuted by the 
modern mode of treatment in that 
disease. Locally an attempt to secure 
an aseptic operative field by the use 
of antiseptics is hopeless. The parts 
should be cleansed of secretion by 
douching with warm normal salt solu¬ 
tion, but anything beyond that is 
superfluous. Large faucial tonsils 
which interfere with manipulations 
should first be excised. 

Local application of Hess’s throm¬ 
boplastin recommended as a preven¬ 
tive of post-operative hemorrhage, on 
the basis of 2036 adenoid and tonsil 
operations. J. J. Cronin (Jour. Amer. 
Med. Assoc., Ixvi, 557). 

Practically all the acute infectious 
diseases of childhood have followed 
adenectomy. The writer warns 
against operating in the presence of 
local infection or during epidemics. 
Much thought has been given to the 
reasons for unexpectedly slow and 
limited improvement of the patient in 
some instances of adenectomy, espe¬ 
cially as regards mouth breathing. 
W. E. Grove (Johns Hopkins Hosp. 
Bull., Apr.,- 1913). 

Bleeders should be avoided, or pre¬ 
pared by a few doses of calcium chlo¬ 
ride or lactate. The strange conflict 
of opinion, both in the laboratory and 
the clinic, as to the effect of calcium 


378 


ADENOID VEGETATIONS (KNIGHT AND CARISS). 


upon the coagulability of the blood 
tends to weaken confidence, but pos¬ 
sibly should rather teach us to use it in 
larger doses than has hitherto been 
the custom. The weight of evidence is 
strongly in favor of calcium lactate, 
some authorities asserting that the chlo¬ 
ride is practically inert (W. K. Simp¬ 
son). The former is more agreeable to 
take, and thus far no unpleasant con¬ 
sequences from larger doses have been 
experienced. 

Clinical experience shows that cal¬ 
cium lactate has a controlling influ¬ 
ence in hastening the coagulation of 
the blood. Its efficacy is more 
marked in hemophilic cases where 
the coagulation is delayed than in 
cases of normal coagulation time. 
Before operation, especially on ton¬ 
sils and adenoids, careful inquiry 
should be made relative to any hemo¬ 
philic heredity or tendency. In sus¬ 
picious cases the coagulation period 
should be determined before opera¬ 
tion. It is questionable, if not posi¬ 
tively contraindicated, whether such 
operations should be undertaken in 
hemophilic cases other than under the 
most extreme urgency. In all cases 
of operation for the removal of ton¬ 
sils and adenoids, calcium lactate 
should be given for a period prior to 
and after the operation, both for its 
possible effect in diminishing the im¬ 
mediate hemorrhage and in prevent¬ 
ing secondary surface hemorrhage. 
Of the calcium salts, the lactate is 
more positive in its results, is more 
agreeable to administer, and is less 
irritating to the stomach. Simpson 
(Medical Record, Sept. 25, 1909). 

The writer submits the following 
hints on the tonsil-adenoid operation 
based on an experience of 5000 cases: 

1. In middle suppuration, always ex¬ 
amine for adenoids. The same rule 
holds good in the familiar fleeting 
acute catarrhs of the middle ear. 2. 
In acute suppuration of the middle 
ear do not operate on the throat until 
the acute ear symptoms have sub¬ 
sided. 3. Before operating make sure 


that the mouth is reasonably clean. 
4. Avoid passing the finger into the 
nasopharynx after the operation has 
been finished. If it is necessary, use 
rubber gloves. 5. Severe tonsillar 
hemorrhage, though often termed re¬ 
actionary or secondary, is seldom 
either. It is usually primary. 6. 
After all operations on the nose or 
throat, the patient, no matter what 
his age, when put back to bed should 
not be allowed to lie on his back. 
He should be laid semiprone on his 
side with face turned half-down, and 
with a basin or bowl under the mouth 
and nose. 7. Always visit the patient 
not later than three hours after the 
operation. 8. When about to exarnine 
the bleeding throat of a conscious 
patient, first of all insert a mouth- 
gag. 9. No case of deafness can be 
considered properly examined with¬ 
out the nasopharyngoscope. D. 
McKenzie (Pract., Aug., 1917). 

The bowels should be evacuated by 
a saline laxative and no solid food 
and no milk given for at least six 
hours beforehand. 

Position of the Patient.—The erect 
position is advocated by some, because 
it is that to which we are accustomed 
in routine work, the loss of blood is 
less, and debris and blood tend to escape 
forward rather than backward toward 
the glottis. Moreover it is thought that 
the ears are in less danger as a result of 
freedom from accumulations at the 
openings of the Eustachian tubes. The 
position 011 the side is favored by others 
on account of the tendency of blood 
and secretions to gravitate to the de¬ 
pendent side and drain off through the 
nose and mouth. 

After all has been said, the recumbent 
position to be the most convenient 
for all concerned and is free from risk, 
provided the anesthesia be not profound 
and the reflexes are preserved. In such 
case foreign material approaching the 
larynx is promptly ejected, and what 


ADENOID VEGETATIONS (KNIGHT AND CARISS). 


379 


finds its way into the stomach is 
thrown up before complete recovery 
from the anesthetic. With attention 
to this point, the so-called Rose’s posi¬ 
tion, the head being dependent, is not 
essential. 

When the operator selects the re¬ 
cumbent position, the body should 
be horizontally on the back, the head 
being neither flexed nor extended. 
With the head extended the cervical 
curve of the spinal column is in¬ 
creased. In this position the operator 
is liable to cut deeply into the struc¬ 
tures of the posterior pharyngeal 
wall, which will be stripped down by 
the curette. A lateral position favors 
the drainage of blood from the phar¬ 
ynx and in no way inconveniences the 
surgeon in removing the tonsils. For 
the latter purpose a small guillotine 
is better than a large one, and is not 
so liable to slip. F. C. Carle (Lancet, 
May 13, p. 1265, 1905). 

Anesthesia.—In children under one 
year the atlenoid growth is so soft and 
friable that it can be readily broken 
down with the fingernail and no anes¬ 
thetic is necessary. An artificial nail 
adjusted to the fingertip (Creswell- 
Baber, Motais) has no advantage 
over a curette, and rather hampers 
freedom of manipulation. Local an¬ 
esthesia with novocaine, apothesine, 
cocaine, stovaine, or alypin is reserved 
for adults and for children old enough 
to be manageable. 

The writer advocates local anes¬ 
thesia, describing its advantages over 
general anesthesia as follows: With 
local anesthesia there is less danger 
of starting up an old tuberculous 
lesion of the lungs, which occurs so 
frequently when general anesthesia is 
universally employed. General anes¬ 
thetics have been known to produce 
nephritis, cardiac and respiratory 
failure, and insufflation pneumonia. 
No cases of abscess of the lung have 
been reported following tonsillectomy 
under local anesthesia. It is avail¬ 


able when general anesthesia is con¬ 
tra-indicated, as in chronic nephritis, 
respiratory disorders, pulmonary tu¬ 
berculosis, etc. Local anesthesia has 
an advantage in the rapidity with 
which the operation may be done 
without the shock which follows 
a general anesthetic. When the case 
is uncomplicated, local anesthesia is 
a time-saver and requires fewer 
assistants. 

Local anesthesia is contra-indicated 
in children under 10 years of age, in 
secondary operations, when there 
have been repeated attacks of peri¬ 
tonsillar abscess, and in highly neu¬ 
rotic adults or those with extremely 
sensitive throats. One-half per cent, 
novocaine (procaine), with 1 drop of 
Liooo adrenalin to each dram (4 Gm.) 
of the anesthetic, is preferred, 1 dram 
of the mixture being injected between 
the capsule and muscle of each ton¬ 
sil. The same solution is used for 
adenoids. F. O. Lewis (Therap. Gaz., 
xliii, 328, 1919). 

The writer advocates the use of 
nitrous oxide anesthesia in the re¬ 
moval of tonsils and adenoids in chil¬ 
dren less than 14 years of age. In 
older patients cocaine and procaine 
are used. Yorke (Brit. Med. Jour., 
Aug. 28, 1920). 

Although certain statistics, like those 
given by C. A. Parker, from Golden 
Square and St. Bartholomew’s Hos¬ 
pitals, are partial to chloroform, it is 
the general belief that this agent is 
especially dangerous in lymphatism and 
should never be used (F. W. Hinkel). 
The danger is said to be less when it is 
joined with oxygen. Nitrous oxide 
gas is universally admitted to carry 
the least risk, but it is too transient 
for any but the simplest case. Com¬ 
bined with oxygen, its effect is 
slightly more prolonged and in other 
respects it is satisfactory (W. E. 
Casselberry). When used as a pre¬ 
liminary to ether in what is known 
as the gas-ether sequence, with a Ben- 


380 


ADENOID VEGETATIONS (KNIGHT AND CARISS). 


nett inhaler, the process of narcosis 
is rendered as agreeable, rapid, and 
safe as possible. By this method a 
much smaller quantity of ether is 
needed with proportionate reduction in 
stimulation of mucous secretion and 
less of unpleasant after-effect, two of 
the chief objections to ether. Braden 
Kyle quotes Royer to the effect that 
secretion is lessened by adding to the 
ether a few drops of oil of Hungarian 
pine. The disagreeable odor of ether 
may be partially prevented by first 
pouring a little cologne water in the 
mask, and thus the confidence of a 
timid patient may be secured. By many 
operators the “drop” method of giving 
ether is preferred, especially in young 
children, and thereby the strain upon 
the chest walls incident to the use of 
a closed inhaler is avoided. By some 
the use of morphine, atropine, or chlo- 
retone to reduce mucous secretion is 
advised, but this is not to be recom¬ 
mended in the very young. A clear 
operative field may be procured by 
means of some form of suction de¬ 
vice, now so generally in use. 

Those who oppose general anes¬ 
thesia refuse to admit the fact that 
the shock without it, especially in a 
nervous child, overbalances any risk 
incurred when the plan just outlined 
is pursued. It is almost indispensa¬ 
ble when, as often happens, the palatal 
tonsils must be removed or other in¬ 
strumentation done at the same time. 

Ethyl bromide and ethyl chloride, 
the latter said to be the less objec¬ 
tionable, have no supreme advantage 
and are not free from risk. Accord¬ 
ing to Lermoyez, the difficulty in 
regulating the dose of ethyl chloride, 
owing to its great volatility, is over¬ 
come by giving it with a suitable 
mask, whereby the quantity inhaled 


is precisely known. The Apperson 
inhaler is highly recommended, from 
3 to 5 grams of the anesthetic being 
required for a short operation. The 
drug is so rapidly eliminated that 
after-effects are few or absent. Other 
good features claimed for it by those 
experienced are ease of administration 
and rapidity of action. It may be 
given prior to other anesthetics, or 
alone continuously for an indefinite 
time without regard to the position of 
the patient, upright or prone (G. F. 
Hawley). 

At the Royal Infirmary of Edin¬ 
burgh, the experience of T. D. Luke 
has been so gratifying that he rec¬ 
ommends ethyl chloride as a matter 
of routine for short operations. On 
the other hand Z. Mennell, at St. 
Thomas’s, London, notes the frequent 
occurrence of pulmonary embolism at 
that institution since the introduction 
of ethyl chloride. He attributes it to 
increased coagulability of the blood 
caused by the drug, and on this ac¬ 
count has abandoned its use. Those 
who advocate ethyl bromide ascribe 
disasters with it to the use of an im¬ 
pure product, or to the mistake of 
having substituted for it ethylene 
bromide. In addition we are enjoined 
to give it en masse, admitting no air, 
and to continue the administration no 
longer than one minute (A. R. Solen- 
berger). Most operators will find 
sixty seconds too short a time for 
thorough work. 

The Schleich inhalation mixture 
(E. Mayer) and the A. C. E. mixture 
are urged by some, but have no spe¬ 
cial attraction. 

If the operation is to be done in the 
upright position, it is customary to 
give the anesthetic to the patient 
lying down and to slowly elevate the 


ADENOID VEGETATIONS (KNIGHT AND CARISS). 


381 


body when all is ready. Special oper¬ 
ating chairs have been devised for 
this purpose (T. R. French). 

The question of safety being of the 
first importance, too much stress can¬ 
not be laid upon the necessity of 
choosing a reliable anesthetic and a 
trustworthy anesthetist, and ether 
or nitrous oxide-oxygen ether is the 
safest and the anesthetic of preference 
if general anesthesia is used. 

Insufflation anesthesia, or the forc¬ 
ing of ether vapor to the lungs 
through a tracheal tube (Jackson 
direct laryngoscope), is pronounced 
by C. A. Elsberg, of Mount Sinai 
Hospital, who introduced' the method 
and devised an excellent apparatus 
for the purpose, "ideal” in operations 
in the upper air tract, as regards pre¬ 
vention of aspiration of blood and 
mucous and as to rapidity and safety 
of narcosis. This view is confirmed 
by C. H. Peck from experience with 
a number of cases at Roosevelt Hos¬ 
pital. 

Gas and oxygen passed over anes- 
thol for the induction of anesthesia, 
and gas-oxygen-ether to maintain it, 
are employed by the writer in aden¬ 
oid and tonsil work. His equipment 
consists of an electric heater for 
warming the anesthetic and a vapor 
mask with Sanford nasal tubes or a 
mouth hook and a Whitehead self- 
retaining mouth gag. Anesthol is 
placed 'in one bottle of the ether at¬ 
tachment, and ether in the second 
bottle. The induction is begun with 
nitrous oxide and oxygen, and after 
15 to 30 seconds the anesthol is 
turned on gradually. In from 1 to 3 
minutes the third stage of anesthesia 
is reached, usually without a strug¬ 
gling stage. The ether is then turned 
on very gradually. When the pa¬ 
tient is able to breathe gas-oxygen- 
ether without coughing or hesitation 
in breathing, the anesthol is turned 
off and the anesthesia continued with 


gas-oxygen-ether. The patient’s skin 
remains pink throughout the pro¬ 
cedure and there is no rise in blood 
pressure. In children up to 6 years 
of age the ether may be turned off 
very shortly after the operation is 
begun, the induction of the anesthesia 
being carried through with gas oxy¬ 
gen only, or the gas may be turned 
off and the anesthesia continued with 
ether and oxygen. When the aden¬ 
oids are being removed the nitrous 
oxide and the ether are turned off 
and oxygen is given, the blood being 
thus in the best possible condition for 
coagulation. G. T. Gwathmey (N. Y. 
Med. Jour., cxi, 1065, 1920). 

Instruments and Methods.—Chem¬ 
ical caustics and the electric cautery 
have been generally superseded by in¬ 
struments for extracting the morbid 
tissue instead of destroying it and 
allowing it to slough away. 

Caustics are available, if ever, only 
in tractable patients and under guid¬ 
ance of the rhinoscopic mirror, the 
palate being held forward with a re¬ 
tractor (White) or by means of elastic 
ligatures (flexible catheters) passed 
through the nares and out of the mouth, 
the nasal and buccal ends being tied 
or clamped together. Under cocaine 
the process is not extremely painful. 
Silver nitrate and chromic acid have 
been used in this way. Without the 
utmost care and the use of a guarded 
applicator there is danger of excessive 
damage and violent reaction. The 
electric cautery point or loop is more 
precise and manageable, but at best 
these methods are tedious and un¬ 
satisfactory. They are reserved for 
hematophiliacs and those who refuse 
to be cut. In other cases the cold-wire 
snare, the guillotine, forceps, and the 
curette provide a -wide choice of cut¬ 
ting instruments. A straight snare 
(Jarvis) may be passed through the 
naris, or a curved one behind the 


382 


ADENOID VEGETATIONS (KNIGHT AND CARISS). 


velum (Bosworth). It is successful 
only when the lymphoid tissue is so 
bunched in the vault that the wire 
can readily encircle its base. It is apt 
to slip and include only superficial 
portions. 

The guillotine method, or the com¬ 
bined guillotine-curettage, or the 
guillotine-forceps methods are the 
most commonly used at present. 

The variations of instruments of all 
types are numerous, the main features 
of each type, however, being similar. 

The guillotine type in common use 
is the La Force or some modification, 
and in the average case, removal 
of adenoids by this method 
proves safe and satisfactory. 

The early instruments for 
scraping were the sharp spoons 
of Justi and of Trautmann. Curettes 
are now made larger and of different 
sizes and shapes, and some are pro¬ 
vided with forks to catch the resected 
fragments. Such complicating at¬ 
tachments are a disadvantage rather 
than otherwise. The simpler the in¬ 
strument, the easier it is to handle 
and keep aseptic. 

While the anesthetic is being given, 
the patient lies flat on the back. After 



the muscles are somewhat relaxed, a 
mouth-gag is inserted. If the palatal 
tonsils are enlarged, they are first re¬ 
moved. A little more anesthetic may 
now be required. The nasopharynx 
is explored with the finger to deter¬ 
mine the extent and distribution of 
the growths. 


The instrument of choice is there¬ 
upon inserted behind the soft palate 
and velum, pressed firmly upward and 
backward into the vault of the pharynx 
and, if the guillotine type is used, the 
blade is forced shut and the adeno- 


tome removed with a sweeping motion. 
Digital examination of the pharyngeal 
vault following removal of the main 
mass of adenoid tissue by this means 
may disclose small shreds remaining, 
especially in the region of Rosenmuel- 
ler’s fossae, and these may be removed 
by some form of curette or forceps, 
as the individual operator prefers. 

By many a curette of the Gott- 
stein or Beckmann pattern is used for 
the whole operation. A curette of 
proper shape and size, and correctly 
used, certainly sweeps off the tissue 
most effectually. The blade, always 
quite sharp, is slipped behind the 
velum and crowded from below up¬ 
ward close to the posterior margin of 
the vomer, and then by a quick move¬ 
ment pushed backward and slightly 
downward through the base of the 
growth. A clean, complete removal 
is thus ensured, at least as to the 
vault itself, when the conformation 
of the region is normal. Unless the 








ADENOID VEGETATIONS (KNIGHT AND CARISS). 


383 



blade is passed close to the posterior 
surface of the velum and is made to 
hug the vomer in its upward move-, 
ment, pendent masses are apt to be 
crowded into the choanae. By giving 
the shaft of the curette a curved or 
bayonet shape it is possible to avoid 
the obstacle offered by the incisor teeth 
or by the palate and thus reach far¬ 
ther forward in the vault (J. Fein). 


part is apt to remain vulnerable for 
some time, often highly sensitive to 
atmospheric changes, so that the at¬ 
tacks may not altogether cease until 
steps have been taken to brace up the 
relaxed mucous membrane and re¬ 
duce its susceptibility to chills. It is, 
therefore, advisable to remove the 
patient, soon after the operation, to 
the seaside, choosing a situation 
which is moderately bracing, but not 
bleak. He should be taught to 
breathe as much as possible through 
the nose, and should pass'the greater 


Denhard’s mouth grag. 


Other curettes are made heart- 
shaped, so as to actually enter the 
nares on either side of the septum 
(C. E. Munger). 

The nasal route for reaching ade¬ 
noids has been revived by Freer, who 


part of his time in the open air. There 
are two applications which are very 
serviceable in these cases. Twice a 
day a solution of resorcin in normal 
saline (5 or 10 grains to the ounce, 
with the addition of half a dram of 
tincture of hamamelis) should be in- 



Brandegee’s adenoid forceps. 


recommends for the purpose a modi¬ 
fication of Ingabs straight nasal cut¬ 
ting forceps. The blades are directed 
by the finger passed behind the 
velum, and in any case it is a useful 
instrument for clearing out the post¬ 
nasal arches, where fragments are 
sometimes missed and afterward give 
trouble. 

Even when the postnasal adenoids 
have been completely extirpated, the 


stilled into the nostrils as the child 
lies on his back with his head sup¬ 
ported by a pillow. Five or six drops 
may be used to each nostril with a 
“dropper,” allowing the fluid to trickle 
down into the pharynx. After using 
these drops for a week we can begin 
to paint the pharynx. The best ap¬ 
plication for this purpose is a solution 
of 15 grains of potassium iodide and 
12 of iodine in an ounce of water, 
well sweetened with glycerin. This 
should be applied twice a day to the 




384 


ADENOID VEGETATIONS (KNIGHT AND CARISS). 


pharynx with a brush, taking care to 
sweep the brush round with a turn 
of the wrist before withdrawing it, 
so as to reach as high up as possible 
behind the soft palate. This applica¬ 
tion not only checks morbid over¬ 
secretion by curing the nasopharyn¬ 
geal catarrh, but also puts an end to 
laryngeal irritation and favorably in¬ 
fluences the glandular enlargement. 
In fact, this is the very best method 


treatment does cause shrinkage of 
tonsils and adenoids and an in¬ 
creased fibrosis and an atrophy of the 
lymphoid constituents of these struc¬ 
tures, but whether the diseased pro¬ 
cess is arrested—and this and not size 
is the usual indication for treatment 
or removal—remains to be proven, in 
view of the divergence of opinion. 



Knight’s adenoid forceps. 


of treatment for acutely swollen cer¬ 
vical glands, and as long as the latter 
remain of elastic softness, varying in 
size from time to time according to 
the amount of laryngeal worry, we 
may expect them to be dissipated by 
this means. Smith (Practitioner, Jan., 
1910). 

Recently, much has been done and 
much has been reported regarding 
the treatment of diseased tonsils and 
adenoids by means of X-ray and 
radium. 


The author’s experience has been that 
but little, if any, change has been pro¬ 
duced in the diseased condition and 
operation has been necessary in many 
cases which have previously been ex¬ 
posed to X-ray or radium treatment. 

The chances of recurrence in the 
ordinary case diminish rapidly from 
the age of 4 to 7 after which they 
are practically nily unless anterior 
nasal obstruction exists or measles 
or whooping-cough supervenes. T, 
Guthrie (Lancet, Apr. 20, 1912). 




Gottstein’s adenoid curette. 


Many of the adherents of these 
methods have made claims of remark¬ 
able results and have advocated treat¬ 
ment by such means instead of surg¬ 
ical removal. 

The opinions of the writers for and 
against this method are so divergent 
and so numerous that the conclusion 
must be reached that these methods 
of treatment are still on trial. 

Undoubtedly X-ray or radium 


Accidents and Complications.—The 
most serious accident is hemorrhage, 
which may be first shown by pallor and 
rapid, flickering pulse. Small children 
should be closely watched and not 
allowed to sleep continuously for sev¬ 
eral hours after operation. The con¬ 
trast between the quiet and the pre¬ 
viously noisy breathing often creates 
enough anxiety to enforce this cau¬ 
tion. Bleeding usually ceases spon- 








ADENOID VEGETATIONS (KNIGHT AND CARISS). 


385 


taneously in a very few minutes. The 
total loss of blood is difficult to esti¬ 
mate; according to C. G. Coakley, 
from 2 to 8 ounces is the ordinary 
quantity. If in excess or too long 
continued, measures to check it must 
be adopted. 

Operations upon the pharyngeal 
tonsils are generally considered with¬ 
out danger, yet wound infection and 
hemorrhage, although comparatively 
rare, do occur frequently enough to 
warrant careful attention. Hemor¬ 
rhages may be divided into 2 types: 
those appearing at the time of opera¬ 
tion, and those occurring some time 
afterward. 

In the first instance the causes lie 
in a constitutional or a local condi¬ 
tion, the most important of which is 
hemophilia. This is shown by family 
and personal history. If there exists 
absolute proof of a hemophilia, 
naturally the operation would be de¬ 
nied. But in such cases as appear 
relatively doubtful the operation 
should be given the benefit of the 
do-ubt. An unrecognized leukemia 
can be the cause of excessive hemor¬ 
rhage. Characteristic is the livid 
bleached color of the tonsils. Opera¬ 
tion in such cases can produce the 
same untoward results as in hemo¬ 
philia. Among other diseases which 
impose the danger of severe post¬ 
operative hemorrhage are nephritis, 
heart lesions, etc., which, however, 
appear so rarely in cases needing 
adenoidectomy that they can be 
neglected. 

Many authors have associated se¬ 
vere postoperative hemorrhage with 
the coincidence of the operation and 
menstruation. About 1 per cent, of 
cases have postoperative hemorrhage. 
Injury to neighboring parts, and es¬ 
pecially the leaving of partly removed 
tissue shreds, are the important fac¬ 
tors. The former more often leads 
to hemorrhage immediately following 
the operation, and only to after¬ 
bleeding when the blood-clot cover¬ 
ing the lesion is accidentally removed. 

1—25 


Mucous membrane shreds hanging 
from the wound are found in over 
50 per cent, of after-hemorrhages. 
Hemorrhages occurring after several 
days generally follow sudden muscu¬ 
lar exertion, such as sneezing, blow¬ 
ing the nose, etc., and are due to dis¬ 
location of the exudate covering the 
wounded surface. Healing had pro¬ 
gressed so far after a week’s time that 
bleeding is no longer to be feared. 
Haymann (Archiv f. Laryngologie, 
Bd. xxi, S. 15, 1908-1909). 

Reference has already been made to 
the internal use of calcium chloride 
or lactate in hemophilia, and many 
local applications are advocated such 
as thromboplastin, hemoplastin, coag- 
ulen, and thrombokinase. Locally, in¬ 
stillations of adrenalin chloride, 1 to 
IDOO, are sometimes effective. Direct 
pressure by means of a gauze tampon 
crowded up into the vault in the 
grasp of a postnasal forceps is usually 
successful. At times it may be neces¬ 
sary to retain the postnasal gauze 
tampon in situ for several hours, hav¬ 
ing pulled it up firmly in the vault of 
pharynx by means of tape through 
nostril and securing tape externally 
by means of adhesive plaster. The 
gauze may be soaked in a saturated 
solution of tannogallic acid (1 part 
gallic, 3 parts tannic), one of the clean¬ 
est and most active hemostatics. 
Signs of collapse are to be combated 
by saline injections, stimulants, con¬ 
stricting the extremities, and similar 
expedients. Even after extreme ex- 
sanguination the repair of waste is 
generally rapid, but may need to be 
encouraged by the use of ferruginous 
tonics or other medication. 

Such being the case, the proposal 
of Iglauer to transform adenectomy 
into an “almost bloodless” operation 
by packing the postnasal space with a 
tampon of rubber sponge the moment 


386 


ADENOID VEGETATIONS (KNIGHT AND CARISS). 


the adenoid mass has been removed is 
of doubtful utility. 

The plan suggested is like that fol¬ 
lowed in plugging the posterior nares 
for epistaxis. 

The tampon is ready before the 
operation is begun, and the tape at¬ 
tached to it is used as a palate re¬ 
tractor during instrumentation. 

The handle of the forceps cutting 
laterally should not be too much de¬ 
pressed lest the margin of the vomer 
be nipped between the blades. Care 
should be taken to keep the blade of 
a cutting instrument in the middle 
line of the vault: if tilted to one side, 
there is danger of harm to the Eusta¬ 
chian cushion. 

A rare and interesting complication, 
torticollis, has been described by sev¬ 
eral writers and is probably due to 
sepsis or to excessive energy in the 
use of instruments. It disappears 
spontaneously in a few days and is 
worthy of note only because of the 
unnecessary alarm to which it may 
give rise. 

Laceration of the velum would seem 
to be inexcusable, but has been known 
to occur with rough handling of an ex¬ 
cessively large instrument, or from at¬ 
tempting to make use of a cutting edge 
in a struggling child, or before one 
is quite sure that the instrument has 
passed beyond the plane of the velum 
and is well within the cavity of the 
Inasopharynx. Finally, the mucous 
membrane may be stripped up over 
an excessive area, if too dull an instru¬ 
ment be used, or if it be forced too 
deeply into the tissues. With the ex¬ 
ception of the first-mentioned, hemor¬ 
rhage, these accidents are obviously 
all unfortunate results of faulty ma¬ 
nipulation. 

Reports of deaths from pulmonary 


abscess following operative proced¬ 
ures of the upper respiratory tract 
have been increasingly numerous and 
have stimulated investigation of this 
complication, and have added many 
adherents to the view held by too few, 
unfortunately, that operations in this 
area are not to be seriously consid¬ 
ered. 

There is still a wide divergence of 
opinion as to whether the condition 
is a result of blood stream infection, 
of lymph channel transmission, or 
of direct inspiraton during operation, 
and each investigator holds his own 
view regarding the means of produc¬ 
tion and of the methods and the ap¬ 
pliances for possible prevention of 
this complication. 

Attention has been called by Wyatt 
Wingrave and others to a peculiar 
transitory rash resembling that of scar¬ 
latina at times following removal of 
adenoids or tonsils. It merits notice 
only for the danger that it might be 
confounded with a more serious infec¬ 
tious exanthema. No precise theory of 
the phenomenon is propounded, whether 
septic or nervous, although marked 
leucocytosis is demonstrable for a week 
or ten days after. Several cases of 
alleged sepsis have been recorded, but 
in many the histories are by no means 
conclusive. A case of fatal meningitis, 
believed to be septic, has been reported 
by Shurly; two similar cases have been 
noted by Putnam, who expresses the 
opinion that such sequelae are not un¬ 
common. An interesting case of cav¬ 
ernous sinus thrombosis in which the 
surface of the basilar process of the 
occipital bone had been shaved ofif 
together with an adenoid mass with a 
Beckmann curette is a graphic warning 
against the use of extraordinary force 
(A. E. Wales). Cases of pharyngeal 


ADENOID VEGETATIONS (KNIGHT AND CARISS). 


387 


abscess, inflammation of the cervical 
glands, endocarditis, and acute rheuma¬ 
tism have been met with by various 
observers after adenectomy. 

Several instances of lighting up of 
latent tuberculosis by adenectomy have 
been reported (Lermoyez, Chappell). 
It is perhaps more correct to say that 
tubercle bacilli lying in the operative 
field have ready admission to the cir¬ 
culation through the divided lymph- 
channels, whence general infection fol¬ 
lows. In the majority of cases the 
adenoid tuberculosis is undoubtedly 
secondary to a focus in the lung or else¬ 
where which is excited to activity by 
the surgical shock of operation. In a 
primary case the results of removal are 
favorable (E. H. White), but there 
must always be difficulty in deciding 
this question of priority. 

In the development of pulmonary tu¬ 
berculosis adenoids may sometimes be 
direct channels of infection, but their 
importance is probably more often in¬ 
direct by predisposing to catarrhal in¬ 
flammations of the upper respiratory 
tract. E. Hamilton White (Amer. 
Jour. Med. Sci., Aug., p. 228, 1907). 

The writer found evidences of tu¬ 
berculosis in the growths in only 1 
of 27 cases of adenoid vegetation, and 
in this case it was evidently second¬ 
ary. Wikner (Hygieia, April, 1910). 

An interesting case is mentioned by 
J. L, Morse, in which “adenoids were 
removed from an infant of five months 
during the early stage of tuberculous 
meningitis, tubercle bacilli being found 
in the adenoid tissue.” The possibility 
of infection by this route is looked upon 
as a strong reason for operating in the 
early months of life, even with the 
certainty that a repetition will be called 
for at a later period. 

Spasm of the glottis requiring tra¬ 
cheotomy, as in cases of his own, is 
believed by Holger Mygind to be not 


infrequent in adenectomy without an¬ 
esthesia in rachitic children, and one 
should be prepared for such an emer¬ 
gency. 

The writer has twice witnessed seri¬ 
ous disturbance of respiration (laryn- 
gospasm with stridulous inspiration and 
marked cyanosis of the lips) as a result 
of adenotomy without use of chloro¬ 
form. Both cases were children under 
2 years having symptoms of rachi¬ 
tis. In the third case, in a boy of 2 
years, with rachitic deformities, there 
was sudden collapse accompanied with 
suspension of respiration and cyanosis 
consequent to adenotomy, which re¬ 
quired tracheotomy. The child’s 
mother later declared that the child 
was subject to fits of suspension of 
respiration with cyanosis. On two 
occasions he had such attacks in the 
presence of the family doctor, and 
artificial respiration had to be em¬ 
ployed. Holger Mygind (Hospital- 
stidende, Nov. 18, p. 1173, 1903). 

Case in which a very large adenoid 
removed from a child aged 6 years gave 
rise to asphyxia on spasmodic closure 
of the jaw just as the child was appar¬ 
ently under complete ether anesthesia. 
The writer had to resort to artificial 
respiration, hypodermic injections, 
forcible opening of the jaw, and 
traction of the tongue in order to re¬ 
suscitate his patient. G. L. Richards 
(Laryngoscope, Feb., p. 289, 1905). 

After-treatment. — The control of 
hemorrhage, and that in very excep¬ 
tional cases, is practically the only 
indication for interference during con¬ 
valescence. If catarrhal secretion is 
overabundant, it is sometimes desirable 
to keep the parts clean with a douche 
or coarse ^ray of warm normal salt 
solution. Drainage from this region is 
so good that sepsis is almost unknown, 
and it is well to abstain from the use of 
antiseptics, either in solution or powder. 
In order to prevent the formation of 
adhesions, the passage of the finger 
into the vault for a few days after 


388 


ADIPOSIS DOLOROSA (DERCUM). 


operation has been recommended. Al¬ 
though no statistics on this point are 
available, it is believed that adventitious 
bands met with in adult life are due 
not to operative interference, but to at¬ 
trition and erosion of lymphoid masses 
in childhood which have been neglected 
and have finally undergone spontaneous 
shrinkage. 

Removal of adenoid vegetation has 
brought about, in the writer’s hands, 
recovery 2 cases of exophthal¬ 
mic goiter, 1 of glaucoma due to 
lesion of the fifth pair and not re¬ 
lieved by iridectomy, and of 1 case 
of Addison’s disease. The persistence 
of the craniopharyngeal canal and an 
• accessory pituitary gland encountered 
sometimes in the pharynx, might 

cause an alteration in the secretory 

function of the pituitary body, and 
the sympathetic nerve, through the 
other glands of internal secretion. 
Popp (Annales des mal. de I’oreille, 
du larynx, etc., Oct., 1909). 

The pharynx, as a rule, is relatively 
small in children with adenoids, 

sometimes ■ interfering with respira¬ 
tion, deglutition, and clear speech 
after the adenoids have been re¬ 

moved. It is possible in such cases 
to develop and broaden the bony 
pharyngeal walls by exercises of the 
pterygoid muscles, viz., lateral, ver- 
ticle and anteroposterior movements 
of the lower jaw, made against re¬ 
sistance offered by the hand of an 
instructor who holds the jaw firmly. 
F. Warner (Lancet, Dec. 20, 1913). 

No procedure in the upper air tract 
has added so much to the vigor of 
the race as removal of adenoid vege¬ 
tations, and the fact must be admit¬ 
ted that they are often a source of 
disease, even when their volume is 
not sufficient to cause obstructive 
symptoms. 

Charles H. Knight, 

New York 

AND 

Walter L. Cariss, 

Philadelphia. 


ADIPOSIS. See Obesity. 

ADIPOSIS DOLOROSA; DER- 
CUM’S DISEASE. 

[The term “Dercum’s disease” is that by 
which adiposis dolorosa is generally 
known in Europe. Hence its introduction 
here by the Editors.] 

DEFINITION. —Adiposis dolorosa 
derives its name from its two principal 
features, namely, fat and pain. 

[Objection may naturally be made to the 
form of the word “adiposis,” as it is of 
mixed origin, being made up 'of a Latin 
root joined to a Greek termination. It 
has, however, the sanction of generations 
of use among English-speaking writers, 
and, besides, is paralleled by other mon¬ 
grel words in common use, such as term¬ 
inology, which no one any longer ques¬ 
tions. . The correct Latin form of the 
word would, of course, be “adipositas,” 
the word used by German writers. How¬ 
ever, adipositas is equally a coined word, 
a word artificially made, for it is not used 
by any Latin writer. The real Latin word 
is “obesitas,” which, as purists, we ought 
to use. F. X. Dercum.] 

In 1888, the writer described the 
symptoms which constitute this affec¬ 
tion in reporting a case under the title 
of a subcutaneous connective-tissue 
dystrophy. Later, in 1892, he grouped 
this case, a second described by F. P. 
Flenry, and a third discovered in the 
wards of the Philadelphia General Hos¬ 
pital under the name “adiposis dolo¬ 
rosa,” by which the affection has since 
become generally known. Within the 
next few years cases were published by 
Collins, Peterson, Ewald, Eshner, Spil- 
ler, Eere, and others. In 1901, Louis 
Vitaut (These de Lyon, 1901, “Maladie 
de Dercum”) published a special treat¬ 
ise on the subject. His description of 
the affection was so full and accurate 
that at the present date it needs but lit¬ 
tle modification and but few additions; 
the latter mainly bear upon the pathol¬ 
ogy of the affection. Up to the present 


ADIPOSIS DOLOROSA (DERCUM). 


389 


time between 50 and 60 cases have 
been recorded. [Among the more im¬ 
portant papers upon the subject are 
those of Frankenheimer (Jour. Amer. 
Med. Ass’n, 1908, i, p. 1012), of Price 
(Amier. Jour. Med. -Sci., May, 1909), 
and the thesis of Poirier, Montpelier, 
1910.] 

SYMPTOMS AND COURSE.— 

The development of the disease is usu¬ 
ally slow and insidious. A woman who, 
up to the period of onset, has been 
well and occupied with her usual occu¬ 
pation notices a slight pain or tender¬ 
ness in this or that portion of the body. 
This early symptom of pain is very 
variable in character and in intensity. 
Most often it is a sensation of smarting 
or stinging more or less annoying be¬ 
cause of its persistence. Sometimes the 
pain, even in the beginning, is severe, 
though this is unusual. At other times 
the onset of symptoms is preceded by a 
sensation of cold in regions in which 
pain subsequently makes its appearance. 
As a rule, the pains at first are not very 
pronounced and the patient is for some 
time able to follow her ordinary occu¬ 
pation. Furthermore, the pains are not 
persistent, but recur at intervals, the 
patient being comfortable for hours and 
sometimes for days at a time. Little 
by little the pains become more pro¬ 
nounced, they increase in intensity and 
are then also accompanied by distinct 
local changes. The patient naturally 
examines the part which is painful and 
may note these changes herself. Some¬ 
times there is a little flushing of the 
skin and sooner or later a swelling 
is noted. At first it is hardly appre¬ 
ciable, but gradually becomes more pro¬ 
nounced. The swelling may give a 
sensation to the finger of a rather firm 
localized edema. As a rule, it is in the 
beginning a small nodule,—smaller than 


a walnut, rarely larger. Sometimes a 
number of such swellings are noted at 
the same time. The affection continues 
to evolve, usually slowly; the pains be¬ 
come more intense and more frequent, 
and gradually the tumefactions change 
their character and finally become veri¬ 
table tumors or great tumor masses. 
In rare cases the fatty deposit appears 
to make its appearance without either 
previous or concomitant pain, the pain 
making its appearance only after the 
enlargements or swellings have existed 
for some time. This, as already stated, 
is unusual, the most common history by 
far being that just outlined. 

The pain is quite commonly paroxys¬ 
mal, though in long-established cases it 
may be continuous. In the intervals the 
tumefactions are usually tender or pain¬ 
ful to pressure. 

When the disease is well established, 
we may distinguish, as pointed out by 
Vitaut, 4 cardinal symptoms, namely, 
tumor formations, pain, asthenia, and 
psychic symptoms. 

The swellings may present themselves 
under three different aspects. Some¬ 
times they are small, of variable dimen¬ 
sions, distinct from one another, and 
readily isolated. Under these circum¬ 
stances they present what Vitaut has 
termed the nodular form of the disease. 
Sometimes they form extensive masses, 
invading an entire limb or the segment 
of a limb. To this condition Vitaut has 
given the name of “localized diffuse 
form.” Finally, a tumor, properly 
speaking, may not be present, but the 
entire body may be augmented in vol¬ 
ume in consequence of a hyperplasia of 
the fatty subconnective tissue. This con¬ 
dition Vitaut has called “the general¬ 
ized diffuse form.” 

The Nodular Form.—The nodular 
form manifests itself at first by pains. 


390 


ADIPOSIS DOLOROSA (DERCUM). 


variable in character, stinging, itching, 
smarting, shooting, soon followed by a 
slight redness of the skin and a slight 
induration scarcely appreciable to the 
finger. If we examine the painful area, 
we feel a tumefaction, usually of small 


changes, so that it no longer has the 
appearance of a simple tumefaction, but 
that of an actual tumor. Each increase 
of swelling is preceded or attended by 
characteristic pains. The latter are 
sometimes so sudden in their onset and 




Author’s first case {Dercum.) 


size, at first yielding and later a little 
more resistant. The sensation is that 
of a firm edema, which is not well differ¬ 
entiated from the surrounding tissue. 
The tumefaction appears to develop 
slowly in keeping with successive at¬ 
tacks or crises of pain. Gradually it 
becomes somewhat better defined, its 
volume increases, and its consistence 


so severe as to cause the patient to 
cry out. During the height of the 
paroxysm, the tumor may resemble 
very closely, in the sensation which it 
gives to the fingers, a “caking breast.’' 
The painful crisis having passed, it is 
found that the dimensions of the swell¬ 
ing have distinctly increased. It has 
become permanently larger, as well 













ADIPOSIS DOLOROSA (DERCUM). 


391 


as more resistant and better defined. 
After repeated paroxysms, the swelling 
resembles a distinct tumor more and 
more closely. In certain portions, the 
mass may appear finely lobulated, while 
in other parts it gives to the fingers the 


capsulated. Sometimes after a crisis 
we discover around the tumor a well- 
defined edematous zone, which in sub¬ 
sequent crises undergoes a transforma¬ 
tion such as the original mass itself had 
undergone. In this way the mass may 



Case of adiposis dolorosa in a male. (Dercum.) 


sensation of a bag of worms beneath 
the skin. Each painful crisis leaves be¬ 
hind it very appreciable changes. In 
an area where nothing existed pre¬ 
viously, we find after a crisis a diffuse 
edematous tumefaction; if the tume¬ 
faction has existed previous to the 
crisis, we find it transformed into a 
lobulated tumor more or less well en- 


eventually attain great size. The vari¬ 
ous stages of the evolution of these 
masses can be followed very closely by 
palpation. One and the same patient, 
besides, usually presents in various 
regions tumors in various stages of 
development. 

Painful crises supervene usually with¬ 
out appreciable cause; at times they are 






392 


ADIPOSIS DOLOROSA (DERCUM). 


provoked by trauma and at others they 
ensue upon unusual exertion. The pa¬ 
tient is frequently very positive in 
stating that slight contusions of the 
surface or that excessive fatigue pro¬ 
vokes the painful crises. 

The tumors are, of course, variable 
in size. Some of the very smallest 
may be no larger than a pea, though 
so small a mass is the exception. More 
frequently the mass is of the size of 
a walnut or a small orange. Much 
larger sizes are met with. The larger 
masses are of course evident to ordi¬ 
nary visual inspection; the smaller ones 
require to be sought for by palpation. 
If we examine the patient attentively 
in a good light, we are struck by the 
changes in the skin in certain areas. 
In places, indeed, it presents a bluish 
tint due to a slight superficial veining, 
and if we examine such a region by the 
feel we frequently discover a small 
subjacent tumor. Small as the tumor 
may be, it may betray its existence by 
this bluish tint in the skin which covers 
it. It happens sometimes that these 
small tumors become confluent and 
finally form a single large mass. Such 
a mass gives rise to a sensation like that 
of a varicocele or of a bag of worms. 

The masses do not appear to have a 
special localization; they are sometimes 
symmetrical in the beginning, but soon 
group themselves without any apparent 
order. They develop by preference 
over the limbs or in the segments of a 
limb. In some patients it is limited to 
the arms and thighs, or forearms and 
legs in others. Sometimes we find them 
on the tlK)rax, abdomen, and lumbo¬ 
sacral region. The face, hands, and 
feet are never involved. 

The relations of these neoplasms to 
the surrounding tissue* vary according 
to the degree of their development. In 


the state of edematous swelling, they 
pass without exact limitation into the 
surrounding tissue. The skin is but 
slightly movable over them. Later, 
when they form distinct tumors, more 
or less encapsulated, they are mobile in 
all directions and the skin which covers 
them may be folded above them. How¬ 
ever, they are slightly adherent to the 
latter, so that if one tries to displace the 
superjacent skin the movement is trans¬ 
mitted to the underlying tumor. Fi¬ 
nally it may be noted that these masses 
are painful not only during the crises, 
but are very tender to pressure, and this 
tenderness, as already pointed out, may 
persist in the intervals between the 
paroxysms. 

The Localized Diffuse Form.—The 
localized diffuse form may present it¬ 
self primarily or it may develop out of 
the nodular form. When it develops 
from the nodular form, it is because 
the nodules multiply so rapidly that they 
unite and become confluent. In this 
way a more or less voluminous mass 
may develop, which involves a portion 
of a limb or it may be a segment of a 
limb or even an entire limb. However, 
this is not the usual method of origin 
of the localized diffuse form. In the 
nodular form the separate masses are 
generally so small and the evolution so 
slow that the patient has usually been 
under observation for some time before 
the masses become confluent. More 
frequently the localized diffuse form 
originates spontaneously and rapidly in 
an entire limb or a segment of a limb. 
In such a case the pains are felt over a 
correspondingly extensive region. At 
first the entire region presents an 
edematous swelling easily observable by 
the eye. Subsequently the evolution of 
the mass is substantially the same as in 
the nodular form. Painful crises are 


ADIPOSIS DOLOROSA (DERCUM). 


393 


here again present and the swelling in¬ 
creases in size with each successive 
attack. Finally, a mass is formed which 
is resistant and painful to pressure. It 
may be quite smooth or it may be finely 
lobulated, or separate, apparently en¬ 
capsulated tumors may be found im¬ 
bedded in the general lipomatous mass. 

Naturally, in the localized diffuse 
form it is difficult to make out the 
limitations as clearly as in the nodular 
form. The masses involve more espe¬ 
cially the limbs, excluding save in the 
rarest instances the hands, the feet, and 
the face; not rarely they are found on 
the thighs and on the back. The tume¬ 
faction may be excessively painful and 
may present during a crisis the sensa¬ 
tion given by a breast distended by 
milk or, to repeat a term already used, 
a “caked breast.” 

The Generalized Diffuse Form.— 
The generalized diffuse form is much 
less characteristic than the nodular or 
the localized diffuse form. The origin 
and course of the affection is, however, 
the same. The edema may appear 
rapidly, even suddenly, over the greater 
part of the surface of the body and 
limbs, exclusive again of the face, 
hands, and feet. It increases progress¬ 
ively and produces a general lipoma¬ 
tosis. More frequently it begins in a 
certain part, such as the abdomen, some¬ 
times upon one side, and then diffuses 
itself gradually over neighboring por¬ 
tions of the trunk and limbs. Other 
masses may make their appearance at 
the same time or subsequently, and, be¬ 
coming confluent with the original mass 
and each other, a diffuse lipomatosis 
results. The regions affected are ordi¬ 
narily the arms, the chest, the abdomen, 
the hips, and the thighs. Contrary to 
the case in the nodular and localized 
diffuse forms, the hands and feet are 


not always in this form absolutely free. 
At an advanced stage of the disease, it 
is not unusual to see small masses of 
lipomatous tissue over the thenar and 
hypothenar eminences and even on the 
soles of the feet. In one case the 
writer observed even a slight invasion 
of the face. Only the back of the 
hands and the backs of the feet escape 
invariably the lipomatous invasion. In 
consistence the swelling is resistant, but 
much less so than in the nodular form. 
The mass is spontaneously painful and 
tender to pressure. Sometimes the 
suffering owing to the universal tender¬ 
ness is very great. Occasionally it is 
such as to prevent movement on the 
part of the patient and to immobilize 
him in his bed. 

Of the three forms the rriost common 
is the nodular. It presents a special 
physiognomy, which makes its recogni¬ 
tion easy. The localized diffuse form 
resembles certain forms of ordinary 
lipomatosis, but it is, notwithstanding, 
differentiated by the pain and other 
characteristics still to be considered. 
The pains are never absent. They are 
present either spontaneously or are 
readily elicited by pressure. Usually 
they manifest themselves in both of 
these ways. Most often they pre¬ 
cede the appearance of the edematous 
swelling. Sometimes they come on at 
the same time as the swelling; more 
rarely they are not noted until after 
the swelling has made its appearance. 
Slightly marked and intermittent, they 
become more violent when the disease 
is established. The pains are described 
by the patients as stinging, burning, 
pinching, darting, or even lancinating. 
Most commonly they are darting and 
radiate or diffuse in and about the 
nodules. They do not follow the large 
nerve trunks or indeed any nerves. 


394 


ADIPOSIS DOLOROSA (DERCUM). 


The patient describes them as though 
they were situated in the thickness of 
the masses. The muscles, the bones, 
and joints are not painful. The pains 
are exaggerated or brought on by pres¬ 
sure or handling. If the fatty accumu¬ 
lation is considerable, movement and 
effort may increase the pain to such 
an extent that the patient may be 
obliged to remain perfectly quiet during 
the paroxysm or indeed continuously. 
There is one characteristic which one 
finds in all cases, namely, the parox¬ 
ysmal exacerbations already described. 
Suddenly and without cause or follow¬ 
ing an effort or trauma the patient 
again feels active pain. At the same 
time the new formations increase in 
volume; if it concerns a nodule the 
latter is surrounded by an edematous 
zone more or less extended; if it is a 
case of diffuse swelling the skin in this 
region becomes more tense and the cir¬ 
cumference of the mass increases. As 
the pain subsides, the swelling recedes, 
but never to its former dimensions. 
After each crisis, the volume of the 
new formation is increased. 

All or almost all of the patients pre¬ 
sent the symptoms of a general asthe¬ 
nia. The patient is very readily ex¬ 
hausted. Even in cases in which the 
muscular development is good, this fact 
is early noted. In cases which are ad¬ 
vanced the asthenia is very pronounced. 
Sometimes this is so marked that the 
patient is unable to leave the bed. 
Sometimes she is unable to change even 
her position in bed largely because of 
her weakness, but also because of the 
pain and the enormous increase in the 
size and the weight of the limbs and 
body generally. 

The psychic symptoms are not con¬ 
stant. However, they are very fre¬ 
quently present. A cerebral asthenia 


or ready cerebral exhaustion is rarely 
absent. Many patients present in addi¬ 
tion great irritability; this is at times 
so great as to be attended by a change 
in character and disposition. The least 
opposition may enrage the patient and 
not infrequently she will quarrel with 
her neighbors in the wards to such an 
extent that isolation becomes impera¬ 
tive. Sometimes she thinks that the 
other patients and the nurses are against 
her. The sleep is usually broken and 
disturbed by distressing dreams and 
nightmares. One of Eshner’s pa¬ 
tients was disturbed mentally to such 
extent as to necessitate her commit¬ 
ment to an asylum. Hale White’s 
case had two attacks of mental dis¬ 
turbance. Giudiceandrea has noted 
delusions of persecution and a true 
dementia. 

In several cases lessened sensibility 
to touch, pain, and temperature have 
been noted. In the writer’s first case 
there were found areas of anesthesia, 
while in other areas the sensibility was 
diminished. The same patient com¬ 
plained of velvety sensations in the 
finger tips and in the soles of the 
feet. The case reported by Henry pre¬ 
sented marked disturbances of sensa¬ 
tion. Touch, pain, and temperature 
were sometimes not perceived; at other 
times confused. In Giudiceandrea’s 
case the sensibility to pain, on the other 
hand, was much increased, especially in 
the regions corresponding to the adi- 
posed masses. The thermal sensibility, 
again, was particularly exquisite in the 
regions in which there was no trace of 
the neoplasms. Hyperalgesia was 
noted by Achard and Laubry. Patients 
have also complained of sudden sensa¬ 
tions of cold or heat, of formication, or 
of cramps in various parts of the body. 
Headache is not rare. 


ADIPOSIS DOLOROSA (DERCUM). 


395 


Disturbances of the special senses 
are quite frequent. In some observa¬ 
tions there was noted a narrowing of 
the visual fields; in others various 
subjective sensations, such as phos- 
phenes, muscae volitantes; in one case 
amaurosis was noted, which began to 
disappear from the day that thyroid 
treatment was instituted’ and in a case 
of the writer there was present a 
circinate retinitis,—a mass of partly 
fibrinous and hemorrhagic exudate in 
the center of the retina, surrounded by 
crescents of fatty degeneration in 
Mueller’s fibers. 

Diminution of auditory perception 
has been noted several times. In 
some cases tinnitus more or less 
marked has been recorded. Smell 
and taste were impaired in one of the 
writer’s cases. 

Vasomotor disturbances have been 
very frequently noted. The skin over 
a nodule may present no changes 
whatever; on the other hand, it may 
be noted to be somewhat injected 
during a crisis of pain, or much veined 
and slightly bluish. Occasionally the 
face is much flushed,—the malar re¬ 
gions, the frontal regions—or it may 
be the neck, although no actual indura¬ 
tion or swelling accompanies the change 
in color. 

In some cases cyanosis of the ex¬ 
tremities and transitory edema have 
been noted. Frequently also the 
patient notices that his flesh bruises 
very readily, and it is not uncommon 
to note small ecchymoses on various 
portions of the limbs and trunk, and 
at times these evidently make their 
appearance spontaneously and inde¬ 
pendently of trauma. Perhaps, in 
keeping with this fact is the history, 
not infrequently obtained, of excessive 
menstruation or even of metror¬ 


rhagia. At times also epistaxis and, 
in one of the writer’s cases, even 
hematemesis are noted. 

Trophic changes in the form of 
ulcerations, blebs, and bullae have been 
observed. 

It is important also to add that 
there is quite commonly a marked 
dryness of the skin. Patients them¬ 
selves comment upon this and ex¬ 
amination Qonfirms it. 



Adiposis dolorosa with involvement Of 
the joints. {Dercum.) 


Among unusual complications noted 
in adiposis dolorosa are changes in 
the joints. Attention was first directed 
to this by Renon and Heitz, who in 
1901 presented a case of “adiposis dolo¬ 
rosa with multiple arthropathies,” be¬ 
fore the Neurological Society of Paris. 
In addition to the usual symptoms of 
the aflPection there were present marked 
pain, creaking, and limitation of move¬ 
ment in numerous joints. A skiagraph 
of the left knee failed to reveal any 
alteration of the articular surface. The 
knee-cap, however, was a little thick¬ 
ened, and its structure ofifered a some¬ 
what mottled appearance. The syno¬ 
vial membranes gave rise to a slightly 
opaque shadow, which was especially 
evident at the ciil-de-sac under the 





396 


ADIPOSIS DOLOROSA (DERCUM). 


quadriceps tendon. This shadow, In- 
froit, who made the skiagraph, re¬ 
garded as due to fatty thickening of 
the synovial membrane. 

In 1902 the writer placed on record 
(Philadelphia Medical Journal, Decem¬ 
ber 20th) a second case of adi¬ 
posis dolorosa with involvement of 
the joints. Skiagraphs revealed no 
changes whatever in the bones, but 
some thickening of the tissues about 
the joints, especially about the knee- 
joints. The conclusion was justified 
that there was present a marked 
thickening of the synovial membranes 
■and possibly of other structures in 
the neighborhood of the joints. There 
was a marked tendency to the forma¬ 
tion of fringes and rice bodies. The 
joints appeared, as the patient ex¬ 
pressed it, to be “loose,” and motion 
was attended by considerable pain. 
That the changes observed were due, 
in part at least, to fatty infiltration, 
and that this fat was painful, just as 
was the fat in the tumor masses on 
the surface of the body, afforded the 
most reasonable explanation of the 
condition. It was possible also that 
an actual synovitis was present. 
Rheumatism could not offer an ade¬ 
quate explanation of the conditions 
found, while rheumatoid arthritis was 
excluded by tlie absence of changes 
in the bones and cartilages. More 
recently Price has made studies in 
the joints of two other cases con¬ 
firming these findings. 

A most interesting case of adiposis 
dolorosa in which bony changes were 
noted in the dorsal vertebrae and in 
the ribs has been placed on record 
by Price and Hudson (Journal Nervous 
and Mental Diseases, April 19, 1909). 
Kyphoses with corresponding de¬ 
formity and reduction in size of the 


vertebrae were noted in the dorsal 
region and confirmed by the skia¬ 
graph. Similar changes were noted 
in the ribs. The authors call atten¬ 
tion to the possible significance of 
these findings when the frequency of 
pituitary changes in adiposis dolorosa 
is borne in mind. 

The course of adiposis dolorosa is 
essentially chronic. Its progress is 
slow, the patient being worse or 
better by turns in accordance with 
occurrence of paroxysms of pain. In 
well-established cases the suffering is 
continuous, subject always to more or 
less marked exacerbations. 

In the majority of cases the patients 
become extremely obese, the weight 
often running from 200 to 300 pounds; 
in others again, in the nodular form, the 
weight may undergo only a moderate 
if any increase. 

The symptoms may be briefly sum¬ 
marized as follows: fatty deposit, 
pain, general asthenia, and psychic 
symptoms. The deposits are present 
either in the nodular, a localized dif¬ 
fused or a generalized diffused form. 
The distinction between these forms 
is of course not absolute, as combina¬ 
tions of the various forms—or transi¬ 
tional states—may be found in one 
and the same patient. The deposits 
are found most commonly over the 
trunk, shoulders, arms, and thighs; 
the forearms and legs being less fre¬ 
quently affected and the hands and 
face almost never. Pain and tender¬ 
ness upon manipulation of the swell¬ 
ings are present; spontaneous pain, 
pain occurring in paroxysms, is 
also present unless it happens that 
the patient is observed during an 
interval between paroxysms. Involve¬ 
ment of the nerve trunks is rare, though 
it has been a few times observed, not- 


ADIPOSIS DOLOROSA (DERCUM). 


397 


ably in a case of Bergerson’s. Anes¬ 
thesias are rare, hypesthesias not un¬ 
common, paresthesias are frequent; the 
latter consist, as already pointed out, of 
sensations of numbness, cold, burning, 
tingling, crawling. 

The general asthenia and the 
mental phenomena have been already 
sufficiently considered. 

The tendon reflexes may be normal 
or increased, but are usually dimin¬ 
ished and sometimes abolished. In 
one case, that of Delecq, the skin 
reflexes were lost. Coincident gross 
nervous disease has been noted 
several times, bleniiplegia and apha¬ 
sia were noted in one case ; in another, 
a case of the writer, a sclerosis of the 
columns of Goll was revealed at the 
autopsy, and in still another there 
was involvement of the lateral tracts. 

ETIOLOGY. — It is occasionally 
noted that the patient presents a neuro¬ 
pathic heredity; not infrequently grave 
nervous disorders are noted among the 
ancestors or collateral relatives. Now 
and then it is noted that other members 
of the family are unusually stout, e.g., 
in I of Eshner’s cases the mother 
was obese. In a few instances adiposis 
dolorosa has been observed in members 
of the same family. Thus, Cheevers 
reported the case of a man whose 
father and sister both had the dis¬ 
ease, while Hammond reported 2 cases 
occurring among sisters. The striking 
fact in the etiology is the predominance 
of the female sex; the ratio is about 6 
women to 1 man. The age at which 
the disease makes its appearance is 
exceedingly variable. The youngest re¬ 
corded case, that of Hale White, began 
at 12 years of age; the oldest case 
recorded was 78 years of age. Ac¬ 
cording to Frankenheimer, the major¬ 
ity of cases in men occur between 


30 and 40 years of age, and in 
women between 30 and 50 years. 

The disease was originally believed 
to occur exclusively in women and 
about the climacteric period; although 
this was the rule in the writer’s experi¬ 
ence, he has known it to begin as early 
as 12, and has seen 3 cases in males. 
He describes in detail 5 cases of the 
affection, 4 in women whose ages range 
from 20 to 42, and 1 in a man aged 
47. These cases all presented the char¬ 
acteristic symptoms of the disease. The 
panniculus adiposus was invariably 
thickened, sometimes to a marked ex¬ 
tent. The skin was red and in depend¬ 
ent parts has a bluish, livid appearance. 
It was painful, sometimes with a feel¬ 
ing of burning, at other times as if it 
were being pierced by a needle. The 
skin of the legs especially, but occasion¬ 
ally that of the trunk and arms also, 
was thick and infiltrated, generally in 
patches, but in some cases in large areas 
involving the whole lower extremity 
except the feet. The latter condition is 
described by the writer as “elephan- 
tiasic edema.” Actual edema was not 
present, the skin did not pit on pressure, 
and no fluid was obtained on punctur¬ 
ing with a needle. Charcot observed 
this condition in connection with indi¬ 
viduals suffering from functional dis¬ 
turbances of the nervous system, and 
named it “cedeme hysterique.” Strub- 
ing (Archiv f. Dermat. u. Syphil., Feb., 
1902). 

Case of adiposis dolorosa, or Der- 
cum’s disease, believed to be unique, in 
a newborn infant. The writer was 
called in consultation to see the child 
on the day after its birth. It was then 
5 weeks old, and, in addition to the 
characteristic irregular symmetrical de¬ 
posits of fat, which were situated on 
the upper half of the body (the lower 
extremities being normal), there were 
two cystic formations of considerable 
size, one on the left posterior aspect of 
the neck and the other on the left 
breast. While lying undisturbed the 
child appeared to be entirely comfort¬ 
able, but the slightest movement was 
attended with pain. W. C. Walser 


398 


ADIPOSIS DOLOROSA (DERCUM). 


(Boston Med. and Surg. Jour., June 
30, 1910). 

Occasionally the patient presents a 
history of antecedent alcoholism or of 
syphilis. As Price says, the toxic ef¬ 
fects of alcoholism and syphilis are well 
known and the fact that they frequently 
cause degenerative changes in the duct¬ 
less glands has-been emphasized by 
Lorand. This is suggestive when we 
learn of the role which the ductless 
glands appear to play in adiposis dolo¬ 
rosa. In a case described by E. W. 
Taylor, the disease developed while 
the patient was convalescing from an 
acute alcoholic neuritis. In quite a 
number of cases excessive menstrual 
flow and even uterine hemorrhages 
have been noted. In one case, that of 
Spiller, the adiposis dolorosa followed 
ipregnancy, while in another, that of 
Schlesinger, it followed an abortion. 
Quite a number of cases finally have 
developed after the menopause. 

Occasionally trauma is noted in the 
history, and the importance of this fact 
has been especially insisted upon by 
Guidiccandrea. In a case of the writer’s 
and in one of Eshner’s, trauma seemed 
to be the direct exciting cause. Emo¬ 
tional shock has also preceded the 
onset, as in the case of Achard and 
Laubry. In Vitaut’s case there ap¬ 
peared to be a mild infection of the 
digestive tract; in other cases expos¬ 
ure to cold and dampness, rheuma¬ 
tism, appeared to play a role. Occas¬ 
ionally also some other neurosis exists 
side by side with the affection, as in 
the woman reported by Henry and in 
a man reported by the writer, both of 
whom suffered from epilepsy. In other 
cases again, undoubted mental disease 
has been noted; sometimes indeed, as 
in one of Eshner’s cases, commitment 
to an institution becomes necessary. 


Case of adiposis dolorosa in a 
woman aged 80, the mother of 5 
children, who had fallen 15 years be¬ 
fore, after which accident an opera¬ 
tion was performed upon her hip, 
some bloody fluid being evacuated. 
Since that time her legs have been 
weak. Pain appeared in the left hip 
and lumbar region, always along the 
nerves. She grew stouter very grad¬ 
ually. The fat is in large masses 
about the malleoli, hips, calves, but¬ 
tocks, abdomen, forearms, and backs 
of the arms especially. Debove 
(Presse med., July 17, 1901). 

Case in a woman, aged 61 years, 
who, with an apparently unimportant 
family history, dates her troubles 
from a fall from a chair years before. 
The left eye became blind, and the 
left side of the nose developed a tu¬ 
mor. The adiposis appeared in her 
thirtieth year, in the right leg first, 
and then in the left. The arms were 
next attacked. Pain accompanied all 
the early symptoms. When examined, 
the patient’s neck and the subclavicu- 
lar region, as well as the abdomen, 
besides the limbs, were loaded with 
fat. An enormous fatty tumor was 
also present on the internal aspect of 
the left thigh. The buttocks were 
immense. The pores of the skin were 
enlarged. Pain, lasting two or three 
days, in the fatty region was not un¬ 
common. Sensation and temperature 
were normal; the corneal reflex was 
absent, as well as the patellar and 
Achilles. Mentality was normal, but 
there was great asthenia. The writers 
attribute the disease to some affec¬ 
tion of the pituitary. Delucq and 
Alaux (Presse med.. Sept. 17, 1904). 

A typical case with the onset of the 
disease at the early age of 14, and the 
symptoms also unusual. Generally 
the deposits of fat are tender, and 
spontaneous pains (commonly of a 
neuralgic or rheumatic order) are 
slight and only appear occasionally; 
in this case, however, there was 
scarcely any pain on pressure, and 
there were spontaneous burning sen¬ 
sations and an inner sensation pf 
great tension. The writer attributes 


ADIPOSIS DOLOROSA (DERCUM). 


399 


these intermittent pains to a probable 
accumulation of water in the fatty 
tissue, and perhaps in the muscula¬ 
ture also. Grafe (Miinch. med. Woch., 
Mar. 19, 1920). 

PATHOLOGY. —Up to the time 
of writing, eight autopsies have been 
held. These indicate that in adiposis 
dolorosa there is some disturbance of 
the internal secretions, excessive forma¬ 
tion of fatty tissue, and an interstitial 
neuritis of the nerve-fibers contained in 
the deposits. 

[Price has summarized the results of the 
various autopsies as follows:— 

Cases I and II.—Dercum: Macroscopic 
disease of the thyroid, the glands being en¬ 
larged and the seat of calcareous infiltration. 

Case III.—Dercum: Irregular atrophy of 
the thyroid, extensive interstitial neuritis of 
peripheral nerves in fatty deposits, degenera¬ 
tion in the columns of Goll. 

Case IV.—Burr: Glioma of the pituitary 
body; colloid degeneration, with atrophy 
and absence of secreting cells in many acini 
of the thyroid gland; interstitial neuritis of 
terminal filaments; sclerotic ovaries. 

Case V.—Dercum and McCarthy : Adeno¬ 
carcinoma of pituitary body, thyroid nor¬ 
mal, right suprarenal gland hypertrophied, 
hemolymph-glands, interstitial neuritis, un¬ 
developed testicles. 

Case VI.—Guillain and Alquier: Hypoph¬ 
ysis doubled in size, with marked increase 
of connective tissue in the glandular portion 
and changes suggesting an alveolar carci¬ 
noma; thyroid hypertrophied, with increase 
in connective-tissue stroma. 

Case VII.—Price: Inflammatory changes 
in thyroid, with marked increase in the inter¬ 
stitial connective tissue, one whole lobe being 
especially infiltrated, the other showing 
compensatory hypertrophy. Inflammatory 
changes in hypophysis, with presence of a 
condition suggesting alveolar or glandular 
carcinoma, interstitial and parenchymatous 
neuritis, sclerotic ovaries. 

Case VIII.—Price: Marked increase in 
the connective tissue of the thyroid gland, 
dilatation of the acini, with infoldings of the 
cuboidal epithelial lining. The same ohanges 
in the hypophysis as were found in Cases VI 


and VII, but less marked. No abnormalities 
of the adipose tissue. F. X. Dercum.] 

Delecq thinks that disease of the 
thyroid, testicle, ovary, and pituitary 
body may be causes of adiposis 
dolorosa. Von Schroeter concludes 
that adiposis dolorosa is due to a 
dysthyroidismus. Pineles regards 
the disease as a result of the disturb¬ 
ance of function in numerous blood- 
glands and that there are present 
hypothyroidism, genital atrophy, and 
changes in the hypophysis. 

The thyroid gland, it will be noted, 
showed unmistakable changes in 7 of 
the 8 autopsies. These changes are 
very interesting and are well illus¬ 
trated by the findings in the third 
autopsy of the writer, in which the 
gland was submitted to microscopic 
examination. A study of the sections 
reveals the gland to be made up of 
three or four different kinds of secret¬ 
ing tissue. In the first place, there 
are large acini distended by colloid 
material. These large acini vary in 
size, and their contents vary also in 
density. The larger acini are globu¬ 
lar in shape, while some of the 
smaller ones are elongated or angular 
in form. The limits of these acini are 
clearly indicated by blood-vessels 
which occupy their walls. The epi¬ 
thelium is a single layer, which covers 
uniformly the peripheries of the 
acini. Contrasted with these there is 
another kind of secreting tissue, 
which is very solid, and in which the 
acini are made out with great diffi¬ 
culty. They consist of cells filling 
interspaces of the stroma, and the 
blood-vessels supplying these acini 
can only be made out in exceptional 
instances. The lumina of these acini 
when they can be made out are 
usually very small. There is here a 


400 


ADIPOSIS DOLOROSA (DERCUM). 


complete absence of colloid material. 
In other portions acini are observed 
which are a transition between the 
more solid nests of cells and the large 
vesicles which contain the colloid 
material. In addition, there is a third 
form of acinus, which is of peculiar 
interest in that the acini present plica¬ 
tions or papillary outgrowths of the 
walls. These plications or out¬ 
growths project into the lumina of 
the affected acini, which contain, as 
a rule, colloid material of lighter 
staining qualities than the larger 
vesicles, although not lighter than is 
contained in some of the smaller 
vesicles. The epithelium of these 
last-mentioned acini appears at times 
to be slightly higher than the normal 
cubical epithelium of the other vesi¬ 
cles. Finally, in some areas, solid 
masses of cells resembling lymphoid 
cells are seen, but these are probably 
young solid acini, like the small acini 
described above, though the limits of 
these acini are irregular, because of 
the absence of preserved blood in 
the surrounding vessels and of the 
absence of definite interstitial frame¬ 
work. 

The changes observed are indica¬ 
tive in part of hypertrophy. Certainly 
this seems to be the only interpreta¬ 
tion which can be placed on the 
numerous small acini which appear 
to be in process of development. 
Whether the large acini, distended 
with more deeply staining colloid 
material, are to be considered old 
acini, containing old or altered colloid 
material, it is, of course, impossible 
to say, but such an interpretation 
does not seem improbable. The pli¬ 
cations and papillary outgrowths 
observed in some of the acini are 
also worthy of comment, in that they 


evidently represent an attempt to in¬ 
crease the secreting surface of the 
acini and are again expressive of 
hypertrophy. 

These findings are very surprising, 
and it is difficult, of course, to frame an 
explanation. It is not impossible that 
we have here a hypertrophy which is 
the direct outcome of a general atrophy 
of the gland; in other words, a com¬ 
pensatory hypertrophy such as Hal¬ 
stead obtained in the dog after partial 
extirpation. The gland was small, per¬ 
haps sufficiently so to determine com¬ 
pensatory hypertrophy. It is probable, 
however, that other factors, c.g., quali¬ 
tative changes of function, also played 
a role in the peculiar symptoms from 
which this patient suffered. It is not 
inconceivable that as a result of de¬ 
ranged thyroid action some substance 
was thrown into the circulation, which 
at one and the same time prevented the 
proper oxidation of the hydrocarbons 
of the food and tissues, and also acted 
as a cause of neuritis and nerve degen¬ 
eration. Whatever the explanation, it 
is interesting to recall the diminished 
sweating and the occasional slowness of 
speech and mental irritability. The in¬ 
terpretation is somewhat difficult; the 
obesity and the dryness of skin suggest 
thyroid deficiency, while the flushing 
of the face, the occasional tachycardia, 
and the psychic symptoms would point 
rather to thyroid excess, and it is safer 
perhaps with Pineles to regard the con¬ 
dition as one of dysthyroidismus. 

Among the most significant findings, 
however, are the changes noted in the 
pituitary body. In 5 of the 6 cases in 
which the pituitary was examined, it 
was found diseased. Thus Burr de¬ 
scribed a glioma of the pituitary, Der- 
curn and McCarthy adenocarcinoma, 
Guillain and Alquier changes suggest- 


ADIPOSIS DOLOROSA (DERCUM). 


401 


ing an alveolar carcinoma and Price 
changes likewise suggesting alveolar or 
glandular carcinoma in 2 cases. The 
detailed findings in the case of Dercuni 
and McCarthy are very interesting. 

The pituitary body was closely ad¬ 
herent to the dural lining of the sella 
turcica, and an attempt at removal of 
the gland revealed a calcareous layer 
from 1 to 3 mm. in thickness, be¬ 
tween the dura and the gland sub¬ 
stance. When this was removed, what 
appeared to be the normal portion of 
the gland occupied the left quarter of 
the mass; the remaining three-fourths 
consisted of a tumor mass. It was of 
the same consistence as the gland struc¬ 
ture, roughened on the surface where 
the calcareous plate had been removed, 
and attached at its farthest end to the 
internal carotid artery. 

The calcareous plate under the 
microscope showed a true bone reticu¬ 
lum infiltrated with the eosinophilic 
cells comprising the tumor mass. Sec¬ 
tions were made transversely through 
the gland and tumor. The tumor mass 
was composed almost entirely of the 
eosinophilic type of cells, arranged 
irregularly, with a minimal amount of 
interstitial tissue. Around the pe¬ 
riphery of the tumor mass the cells 
were arranged in parallel rows, much 
after the type of cell arrangement seen 
in endotheliomata. The tumor mass 
had, on account of the arrangement of 
the cells in rows at its periphery, an 
appearance as if it were encapsulated 
and separated from the normal gland 
tissue. A careful study of the cells of 
the tumor revealed no trace of a regu¬ 
lar arrangement of the cells, such as is 
seen in the acini of the normal gland. 
The individual cells were round, stained 
a pinkish red with eosin, and contained 
a small, deeply staining nucleus. The 


nucleus in some of the larger cells was 
very large and irregular in shape, such 
as is frequently seen in proliferating 
cells. The cells varied greatly in size: 
some were twice the size of the normal 
gland cells; others one-third to one- 
fourth that size. Between these cells, 
and at times in the capillary vessels of 
the tumor mass, small areas of colloid 
material were seen. 

The area of normal gland tissue— 
i.e., arranged according to the normal 
gland structure—is about one-third the 
size of the normal adult gland, and is 
situated between the tumor mass and 
the protuberance, consisting of cerebral 
tissue. The larger portion of the 
glandular acini is perfectly normal. 
At the junction of the latter with the 
nerve tissue, and extending into the 
latter area, are large groups of cells, 
following an alveolar arrangement and 
differing from the rest of the section 
by the deep staining properties of the 
cells with nuclear stains. The posterior 
portion of the gland, composed of 
reticular nerve tissue, is permeated by 
the small, round, deeply staining nuclei 
in such a way as to give the impression 
that the infiltrating process followed 
definite lymph-channels. At the pe¬ 
riphery of the acinous portion of the 
gland, masses of colloid material, of 
sufficient size to be visible to the naked 
eye as minute dots, are inclosed in 
areas lined by rounded cells. The 
tumor mass, composed as it is of the 
same type of cells as make up the 
acinous portion of the gland, must 
necessarily belong to the carcinomata. 
The infiltrating tumor formation, begin¬ 
ning in the acinous portion of the gland 
and involving the cerebral portion of the 
gland, follows the cell arrangement of an 
adenocarcinoma. The arrangement of 
the eosinophile cells of the tumor mass 
-26 


402 


ADIPOSIS DOLOROSA (DERCUM). 


around the periphery of the tumor 
resembles an endothelioma, but the type 
of cell points strongly to a diagnosis of 
carcinoma. 

In commenting upon the involvement 
of the pituitary in the above instance, 
the writers pointed out, that bearing 
in mind the interrelation which exists 
between the thyroid gland and the 
pituitary body, the pituitary body is 
thus brought into relation, though per¬ 
haps indirectly, with a fat-producing 
or fat-destroying function—a relation 
which, up to that time, had not been 
considered. In the light of recent 
observations this subject assumes a 
new importance. Froelich has shown 
that, instead of the symptom-complex 
termed acromegaly, lesions of the hy¬ 
pophysis may be associated with an 
adipositas universalis and genital atro¬ 
phy. In other words, hypopituitarism, 
other things equal, leads to adipositas. 
Further curious and remarkable inter¬ 
relations of function—seemingly anti¬ 
thetical—appear to exist between the 
pituitary and the pineal gland,—the 
pineal gland appearing to have a fat- 
producing and a fat-destroying func¬ 
tion inversely to the pituitary. For a 
detailed presentation of the subject, 
which here would lead us too far afield, 
the reader is referred to Otto Mar¬ 
burg’s interesting paper on “Adipositas 
Cerebralis, a Contribution to our 
Knowledge of the Pathology of the 
Pineal Gland,” Deutsche Zeitschrift fiir 
Nervenheilkunde, 1908, Bd. 36, p. 114. 

In his discussion of the pathology 
of adiposis dolorosa. Price points out 
that sufficient attention has not been 
given the pituitary, which, he suggests, 
is etiologically of almost as much im¬ 
portance as the thyroid. It would ap¬ 
pear, indeed, from the above considera¬ 
tions that the pituitary must be seriously 


considered, and he asks the question 
whether the symptom of adiposis dolo¬ 
rosa may not result from primary dis¬ 
ease of either the pituitary or the 
thyroid gland. It is well known that a 
close interrelation exists between these 
two glands; experimental extirpation 
of the thyroid in animals has been 
found to be followed by pituitary en¬ 
largement and it would seem that dis¬ 
ease of one gland means sooner or later 
disease of the other. Poirier also di¬ 
rects especial attention to the hypophy¬ 
sis, which he evidently regards as the 
most important structure concerned in 
adiposis dolorosa. 

An examination of the fatty deposits 
reveals not only the structure of fatty 
tissue, but also the signs of great nutri¬ 
tional activity. Fragments removed 
during life by the Duchenne trocar in 
the writer’s first case and submitted to 
microscopical examination presented the 
appearance of a connective tissue em¬ 
bryonal in type. The cells were volum¬ 
inous, fusiform and containing large 
nuclei, while the intercellular spaces 
were filled by a transparent substance 
apparently without structure. On the 
whole the appearance was that of a 
lymphoid tissue. In some fragments 
fat cells were numerous and among 
these were cells which evidently had not 
undergone complete fatty transforma¬ 
tion. In some of them the nuclei were 
still very apparent, while osmic acid 
revealed fat drops suspended in the cell 
contents. 

In the autopsy recorded by Dercum 
and McCarthy, the fatty nodules were 
submitted to microscopical examination 
with the following result. Each of the 
larger nodules was composed of cap¬ 
sules inclosing large numbers of small, 
oval, fatty bodies connected with each 
other and with the capsule by delicate 


ADIPOSIS DOLOROSA (DERCUM). 


403 


fibrous bands. These delicate trabecubne 
united and joined thick, jelly-like bands 
attached to the capsule. Sections made 
through the connective-tissue capsule 
and the fatty bodies in situ gave the 
following structure: The capsule was 
composed of several layers of well- 
developed connective tissue. Within 
this capsule a looser areolar tissue is 
met. This tissue is highly vascular, and 
between the vessels is a reticular tissue, 
denser in some areas than others and 
inclosing a large number of mono¬ 
nuclear cells, a few polynuclear cells, 
and large numbers of cells staining a 
tawny color by the Van Gieson stain. 
Scattered through the granular, tawny 
masses many of the mononuclear type 
of cells may be found. In other areas 
granules of blood-pigment in clumps 
may be seen. Wherever the connective- 
tissue trabecul^e penetrate into the con¬ 
gested fat nodule, this same fine, reticu¬ 
lar structure, holding in its meshes rich 
plexuses of blood-vessels, and between 
these a fine reticulum of connective 
tissue filled with a light-yellow granular 
material, with nucleated yellow cells, 
small mononuclear cells, polynuclear 
reagents, as do nucleated red blood- 
cells, and numbers of degenerating red 
blood-cells, may be seen. Some of 
these cells react to many of the staining 
corpuscles, but to the Biondi-Ehrlich 
triple stain they appear more as mono¬ 
nuclear leucocytes. This tissue is iden¬ 
tical in structure with the hemolymph- 
glands found in the immediate neigh¬ 
borhood of the large, congested nodules 
of subcutaneous fat. 

Lying loose in the yellow fat, several 
small, firm bodies, the size of a split 
pea and of a yellowish-brown color, 
were found. These proved on micro¬ 
scopic examination to be hemolymph- 
glands. They were composed of a cap¬ 


sule of connective tissue, from which 
trabeculae of connective tissue spread 
in many different directions throughout 
the body. Within this trabecular net¬ 
work a rich plexus of capillaries was 
found. Between the capillaries a fine 
meshwork of fibers contains large num¬ 
bers of lymphoid cells, with here and 
there groups of red blood-corpuscles. 
Free blood-pigment giving the iron re¬ 
action was found in small quantities 
free in the trabecular network. The 



Fatty nodvile dissected from subctitaneous fat: 
shows the encapsulation of the fat. with nerve- 
fibers branching over it (Dercum and McCarthy.) 


opinion of Dr. Simon Flexner that 
these structures are new-formed hemo- 
lymph-glands was confirmed by that of 
Dr. A. S. Warthin, of Ann Arbor, who 
has written on the subject. 

An examination of the nerves found 
in the fat has shown the presence of an 
interstitial neuritis. There is a diminu¬ 
tion of nerve-fibers, together with a 
marked proliferation of the perineu¬ 
rium and endoneurium. (See illustra¬ 
tion, next page.) 

The chemistry of the subcutaneous 
fat was investigated by Fdsall, who 
especially sought for an increase in 
the fatty acids as this might have had 
to do with the pain and tenderness. 









404 


ADIPOSIS DOLOROSA (DERCUM). 


However, marked free acidity was not 
present. Its amount was rather low, 
lowest of all in the tumor fat, and 
decidedly below that of normal fat. 
The significance of this fact is not 
evident. 

Case in which there concurred adipo¬ 
sis dolorosa with well-marked myxe¬ 
dematous manifestations. In view of 
the frequency of myxedematous symp- 



Section of nerve In subcutaneous fat nodule 
showing interstitial neuritis. A distinct over¬ 
growth of connective tissue is present between 
the nerve-fibers. The number of blood-vessels 
is also increased over normal nerve-tissue. {Der- 
and McCarthy.) 

toms in adiposis dolorosa, we are justi¬ 
fied in accepting a kindred cause of 
both syndromes. That thyroid insuffi¬ 
ciency stands at the foundation of 
myxedema there can be little doubt; 
again, some thyroid alteration was 
found in 4 out of 5 cases of adiposis 
dolorosa which came to autopsy. While 
the seat of the externally visible pa¬ 
thognomonic symptoms of myxedema 
is in the subcutaneous tissues, that of 
adiposis dolorosa is situated in the 
fatty structures. 


Moreover, the improvement of case 
reported following the administration 
of thyroid extract seems to evince with 
certainty that perverse thyroid function 
was, to say the least, an antecedent. 
The yielding of both symptom-com¬ 
plexes to the same medication again 
points to their interrelation or their 
springing from a kindred cause. Thy¬ 
roid therapy cannot, therefore, be util¬ 
ized as a test of differentiation between 
myxedema and adiposis dolorosa, as 
some authors maintain, because both 
syndromes may vanish under its in¬ 
fluence, and, cS in the present instance, 
even at the same time. Heinrich 
Stern (Amer. Jour. Med. Sci., March, 
1910). 

Case of adiposis dolorosa in young 
soldier. The symmetrical and ex¬ 
tremely painful subcutaneous lipomas 
were accompanied by profound as¬ 
thenia, with the picture of typical 
Dercum’s disease. The first lipoma 
developed about 1 month after an 
exceptionally violent effort to lift 
a heavy stone, during which the 
shoulder had become dislocated. 
The pain was intense and the pre¬ 
viously roLust young man grew 
weaker as more lipomas developed. 
They lay free in the subcutaneous 
adipose tissue and were easily re¬ 
moved. The writer concludes that 
the cause is some upset in the bal¬ 
ance of fat production, the result of 
multiple disturbance in the endocrine- 
sympathetic systems. C. Martelli 
(Tumori, May 18, 1918). 

The identity of Dercum’s disease as a 
disorder of the sympathetic system was 
pointed out by Sajous in 1914, in a paper 
read before the Southeastern Branch of 
the Philadelphia County Medical Society, 
and also in abstract in the 1917 Supple¬ 
ment Volume of the Seventh Edition of 
the present work, page 65. Editors. 

DIAGNOSIS. —The diagnosis is 
based upon the presence of the fatty 
masses, presenting the feature of 
pain, spontaneous, paroxysmal, or 
elicited by manipulation, and having 
in addition the physical peculiarities 




ADIPOSIS DOLOROSA (DERCUM). 


405 


already described. The disease is 
readily differentiated from myxedema 
because of non-involvement of the 
face and hands and because of the 
absence of pain in myxedema. When 
the tumor masses are numerous and 
small, they might suggest neurofi¬ 
bromatosis, but the peculiar charac¬ 
ter of the swellings, the fact that 
they appear Icbulated under palpa¬ 
tion, that they are spontaneously 
painful and almost never occur upon 
the face or hands would serve to 
make the differentiation. 

In neurofibromatosis, again, there 
are two kinds of tumors, some of 
them cutaneous, not rarely on the 
face, and others on the mucous sur¬ 
faces. They are of soft, yielding con¬ 
sistence and very slightly painful. 
Others, those of nervous origin, are 
small, very hard, and often grouped 
along the course of the nerve trunks 
like a string of beads. They are 
only laterally mobile, while the adi¬ 
pose tumors are mobile in all direc¬ 
tions and are irregularly distributed. 
Again, anomalies of pigmentation are 
rare in adiposis dolorosa, but are 
frequent and sometimes very pro¬ 
nounced in neurofibromatosis. On 
the whole, it is hardly probable that 
an error could be made. 

In simple obesity, the fat is dis¬ 
tributed throughout all the tissues 
and does not heap itself up in separate 
lipomatous masses, such as is the case 
in adiposis dolorosa,—even in the so- 
called diffuse form. Besides, ordinary 
obesity is painless and is a matter of 
gradual development, while the fatty 
deposit in adiposis dolorosa is painful 
and occurs as the result of successive 
crises. 

PROGNOSIS.—Adiposis dolorosa 
is an affection which is essentially, 


chronic. Most cases live for many 
years and it does not appear to imme¬ 
diately threaten life. However, in 
cases of long standing, a bed-ridden 
period eventually ensues; general 
exhaustion becomes more and more 
marked; degeneration and failure of 
the heart muscle, pulmonary conges¬ 
tion, or a renal complication may 
terminate the picture. The resistance 
to infection also, appears to be greatly 
diminished, for one of the writer’s 
cases died very rapidly of an attack 
of erysipelas. 

Cases in a relatively early stage 
of development—more particularly 
cases with small nodular or localized 
and limited deposits—offer a dis¬ 
tinctly better prognosis and are dis¬ 
tinctly amenable to improvement. 
Advanced cases, cases with very ex¬ 
tensive deposits, marked asthenia, and 
especially with the tendency to sub¬ 
cutaneous hemorrhages and hemor¬ 
rhages from the mucous membranes 
are very unpromising. 

TREATMENT.—In the treatment 
of adiposis dolorosa one remedy has 
in a few cases proved of value and 
that is thyroid substance. This 
should be given in doses of from 
to 5 grains three times daily, for a 
very long time. The salicylates, 
notably aspirin, are of decided value 
in relieving the pain. The best plan 
of procedure, as a matter of course, 
is to place the patient in bed, and to 
institute a systematic course of treat¬ 
ment. The rest should be absolute 
and should extend over several 
months of time. 

Typical case with symptoms of myxe¬ 
dema in which the treatment consisted 
of an antiobesity diet, thyroid medica¬ 
tion, and physical therapeutics, especially 
vibratory massage and exercise. Nine 
months later the patient presented her- 


406 


ADIPOSIS DOLOROSA (DERCUM). 


self to show the beneficial effects of 
the treatment. Excepting the pallor, 
which, she said, had always caused her 
much annoyance since her early youth, 
she looked very well. She felt strong, 
and was able to walk from five to eight 
miles a day; she experienced no short¬ 
ness of breath on ordinary exercise, 
but perspired mildly when she walked 
briskly. The fat Lrnches had disap¬ 
peared almost entirely; the neuralgic 
pains had ceased about four months 
earlier; there was no tenderness on 
pressure on the location of the former 
fat masses. The skin in the supraclavic¬ 
ular regions and in the face had been 
quite tender. She evinced not the 
slightest mental depression and apathy, 
but, on the contrary, displayed a healthy 
optimism. Her weight had been re¬ 
duced to 161 pounds. Heinrich Stern 
(Amer. Jour. Med. Sci., March, 1910). 

Case in a man of 32, married 6 
months, which, the writer thinks, 
throws light on the etiology of the 
disease. The pressure of the man’s 
body against his desk explained the 
unusual location of lipomas, and the 
immediate effect of an injection of 
pituitary extract on retention of 
urine confirmed the influence of the 
pituitary on the Innervation of the 
bladder, but the primal factor in 
Dercum’s disease seems to be some 
abnormal or lacking hormone from 
the organs of reproduction. This 
seems to upset the normal balance in 
the chromaffine system. His patient 
was clinically cured, even to the 
retrogression of the lipomas, by sys¬ 
tematic treatment with thyroid 1 
part; pituitary, 1 part, and of ovary 
2 parts, supplemented by a vegetable 
diet and exercise in the country. 
Whenever this treatment was inter¬ 
rupted, the whole set of symptoms 
returned, even including some of the 
tumors. The patient learned to make 
his organotherapeutic products him¬ 
self, making a cold extract of thyroid 
and testicles, 1:4, from sheep 1 or 2 
years old. (Extraction cold; 50 c.c.; 
phenol, 0.05.) He took a teaspoon¬ 
ful of this extract morning and even¬ 
ing in warm soup. The writer re¬ 


calls that Dercum in describing his 
first case of adiposis dolorosa noted 
its connection with the thyroid. 
Cecikas (Jour. Amer. Med. Assoc., 
from Grece Med., Jan. to June, 1918). 

Case of typical adiposis dolorosa in 
a girl of 16 whose menstruation had 
been suppressed several months. The 
pains returned at monthly intervals. 
Great improvement was observed 
under ovarian extract. After 2 years 
of suspension menstruation returned, 
and since then the paroxysms of pain 
had been much less pronounced. The 
pituitary seemed normal in radio¬ 
graph, as also the thyroid. In an¬ 
other case, a young officer, there were 
small slightly movable lipomas on 
the forearms, absolutely symmetrical, 
which had developed when he was 16. 
Bourdiniere (Progres Med., Sept. 7, 
1918). 

The patient should be weighed 
when treatment is begun and thyroid 
substance given at first in small and 
then in somewhat larger doses. At 
the same time a diet should be insti¬ 
tuted that is largely free from carbo¬ 
hydrates and fats. It should be 
remembered, however, that a diet, no 
matter how rigid, will of itself make 
no impression in adiposis dolorosa; 
it will fail absolutely. It is of course 
wise to institute a careful diet, but 
patients do better when the diet is 
not too strict. Inasmuch as the affec¬ 
tion is attended by a marked asthenia, 
the diet should be nutritious. It 
should consist of the red meats in 
moderation, the white meats freely, 
the succulent vegetables, eggs, and 
skimmed milk. The latter can be 
used between meals and if necessary 
also at mealtimes. 

The pains are not infrequently 
controlled or at least made better by 
aspirin or salophen in full doses, 10 
or 15 grains three times daily after 
meals. Sometimes the tenderness 


ADONIS VERNALIS (SAJOUS). 


407 


and soreness are better borne when 
the limb or part affected is gently 
supported by a flannel roller; if the 
tenderness be extreme a layer of 
cotton-wool may first be applied. 

Just as soon as the tenderness 
permits, gentle massage should be in¬ 
stituted ; sometimes this can never 
be .employed; in other cases again it 
can be instituted comparatively early 
and there can be no doubt that in a 
measure it favors the diminution of 
the swellings, especially if the patient 
can bear deep kneading. Bathing 
between blankets as in ordinary rest 
treatment should also be carried out, 
but of themselves baths accomplish 
nothing in adiposis dolorosa; indeed 
the physical exertion and manipula¬ 
tion attendant upon the application 
of ordinary hydrotherapeutic meas¬ 
ures in these cases exhausts the 
patient. 

It is a good plan to keep a record 
of the pulse and temperature during 
the thyroid administration, although 
the writer has never observed any 
fluctuations of moment in these cases, 
even when the thyroid was pushed. 
The patient should, of course, be 
weighed from time to time and the 
dose of thyroid modified according to 
the impression made. In some cases 
no impression whatever can be made; 
in other cases again the impression 
is decided. In 3 cases of the writer, 
the result was most satisfactory; 2 of 
these were treated systematically by 
rest in bed; the third could not for 
certain reasons be put to bed. In all 
3 the improvement in the size of the 
swellings and in the lessening of pain 
was very great. Treatment was car¬ 
ried out six months to a year. In 1 
case the affection recurred at the end 
of two years, but was again con¬ 


trolled. In the second, improvement 
and practically good health has per¬ 
sisted for four years. The third was 
greatly improved and has disappeared 
from observation. 

The experience of the writer with 
cases in the hospital wards and out¬ 
patient departments has been very 
unsatisfactory partly because many 
of the cases were greatly advanced, 
the deposits being enormous and the 
asthenia grave, and partly because 
the cases could not be kept system¬ 
atically under treatment for a suffi¬ 
ciently long period. 

General tonics, iron, arsenic, strych¬ 
nine may be given, but they do not help 
appreciably. Electricity is useless. 
Finally, it would in the judgment of 
the writer be perfectly justifiable to 
attempt the surgical enucleation of a 
specially painful mass; this procedure 
has not yet been attempted. We 
should bear in mind, of course, that 
these patients have but a feeble 
resistance to shock and often pre¬ 
sent, even to superficial examination, 
marked cardiac weakness. 

F. X. Dercum, 

Philadelphia. 

ADIPOSITAS CEREBRALIS. 

See Obesity and Acromegaly. 

ADONIS VERNALIS. -Adonis is 
a ranunculaceous plant, closely related 
to the anemone, growing wild in Europe, 
Asia, and Africa. Several species of 
adonis are employed ,—Adonis vernalis, 
A. cBstivalis, A. capensis, A. cupaniana, 
and A. amurensis ,—but all seem to 
possess the same properties, although 
the several varieties are variously em¬ 
ployed in the different countries in 
which they grow. In Russia, for in¬ 
stance, it has long been employed in 
cardiac diseases, and in Africa as a 


408 


ADONIS VERNALIS (SAJOUS). 


substitute for cantharides, the bruised 
leaves, when fresh, possessing vesicat¬ 
ing properties. 

DOSE. —An infusion of 4 to 8 parts 
of the plant in 200 of water may be 
given in tablespoonful doses three or 
four times a day (Huchard). The 
tincture may be administered in doses 
of ^ to 1 dram (2 to 4 c.c.). The 
fluidextract has also been used in 
doses of 1 to 2 minims (0.06 to 0.12 

C.C.). 

Cervello isolated a glucosid from 
Adonis vernalis, —adonidin,— a yellow, 
hygroscopic powder having a bitter 
taste, obtained from the leaves. It is 
soluble in water and alcohol, but in¬ 
soluble in ether or chloroform. 
Adonidin is administered in doses 
varying from Yiq to % grain (0.004 
to 0.017 Gm.). It acts more promptly 
than digitalis. 

Inoko also obtained a glucosid— 
adonin—from the Japanese plant, 
Adonis amurensis. This substance is 
free from nitrogen, amorphous, color¬ 
less, of a bitter taste, and soluble in 
water, alcohol, and chloroform. The 
effects observed on the heart of a 
frog were precisely those seen when 
digitalin is used. It is about twenty 
times weaker than the adonidin ob¬ 
tained from the European Adonis 
vernalis. 

PHYSIOLOGICAL ACTION.— 

Adonis resembles digitalis in its 
action upon the heart when given in 
therapeutic doses. It increases car¬ 
diac energy and raises the arterial 
tension. The increased contractions 
eventually diminish and a period of 
quiet follows, varying in duration 
with the dose administered. 

In frogs and dogs the watery ex¬ 
tract caused a marked slowing of the 
heart, owing to stimulation of the 


pneumogastric and its terminal 
branches, the blood-vessels being 
contracted and the blood-pressure 
raised. The alcoholic extract, on the 
other hand, had a very slight effect 
on the frequency of cardiac contrac¬ 
tions, but increased their strength 
and also dilated the blood-vessels, the 
blood-pressure remaining unaffected. 
Slovtzoff (Roussky Vratch, Sept. IS, 
1912 ). 

The prevailing knowledge of the 
mode of action of adonis is based on 
experiments with the glucosid adoni¬ 
din. The results have, on the whole, 
been contradictory. While Cervello 
and Lesage found that it arrested the 
heart in systole, Huchard and Hare 
ascertained repeatedly that this organ 
was arrested in diastole and Guirlet 
found the left ventricle in systole and 
the other cavities in diastole. There 
has been greater concordance in 
respect to its effects on the blood- 
pressure, all observers having found 
that there was first a rise, then a 
fall. 

While the primary slowing is at¬ 
tributed to the inhibitory action of 
the vagus, since its section prevented 
it. Hare found that the diastolic 
arrest was not due to this nerve, 
since it occurred after the latter was 
divided, while galvanization of the 
nerve later on also failed to inhibit 
the heart. He concludes, therefore, 
that adonidin tends secondarily to 
paralyze the vagus—Kakowski, in 
fact, found that it caused dilatation 
of the coronaries instead of contrac¬ 
tion of these arteries. Hare’s experi¬ 
ments indicate that it may also cause 
primary stimulation and secondary 
paralysis of the vasomotor system. 

Adonis has been credited with 
diuretic properties by Bubnow, Alt- 
mann, and Michaelis, though their 
observations have failed to be con- 


ADONIS VERNALIS (SAJOUS). 


409 


firmed by certain others. Whatever 
diuretic power it may have is prob¬ 
ably the result of activation of the 
renal circulation (Wood). 

An unmistakable cumulative action 
and a marked action on the heart 
was observed by the writer. The pa¬ 
tient had taken 6 Gm. (2^2 drams) of 
the drug in an infusion daily for 56 
consecutive days—a total of 396 Gm. 
(13ko ounces). He was a large man 
of 65, hearty, with mitral insufficiency 
and alcoholic cirrhosis. There were 
no signs that the drug was proving 
toxic, no headache, nausea nor pain 
in the stomach, but the pulse of 43 
then developed a typical bigeminus 
form. On suspension of the drug the 
beat returned to the normal type in 
the course of 3 days. Mayor and 
Segond published in 1912 a research 
showing that the digestive juices have 
a destructive action on the active 
principle of adonis. Roch (Arch, des 
Mai. de Coeur, June, 1913). 

INCOMPATIBILITIES. — The 

glucosid adonidin in solution is de¬ 
composed by free acids or alkalies. 
It is incompatible with tannic acid, 
corrosive sublimate, and silver nitrate. 
The physiological incompatibilities of 
adonis include aconite, amyl nitrite, 
muscarin, veratrum viride. 

CONTRAINDICATIONS.—Ado¬ 
nis is contraindicated in arterioscle¬ 
rosis, in affections attended by a 
high vascular tension (as in the 
earlier stages of interstitial nephri¬ 
tis), and in hypertrophy and other 
disorders of the heart in which digi¬ 
talis, its physiological homologue, is 
harmful. 

THERAPEUTICS.—Adonis is use¬ 
ful in cases of valvular heart disease 
with loss of compensation and in which 
evidences of grave circulatory disorder, 
such as cardiac asthma, are present. It 
has been specifically recommended in 
aortic and mitral regurgitation. The 


diuretic powers of the drug cause it 
to be of value in cases of dropsy and 
cardiac degeneration. It is also 
valuable in palpitation dependent 
upon irregular inhibition. As it does 
not seem to possess cumulative tend¬ 
encies, it may be administered with 
more freedom than digitalis. Accord¬ 
ing to Dujardin-Beaumetz, however, 
large doses cause gastric disorders 
and vomiting. Borgiotti found adonis 
valuable in different cardiac disorders. 
One dram to 1 ounce of the infusion 
daily constitutes an excellent cardiac 
tonic. In fatty degeneration of the 
heart it increases diuresis and regulates 
the circulation. 

Adonidin is credited with proper¬ 
ties superior to digitalis, in that it 
acts more promptly and with less 
tendency to cumulation. As Dujar¬ 
din-Beaumetz had observed in the 
case of the infusion of adonis, how¬ 
ever, Lublinski and Durand have 
found adonidin to produce violent 
gastrointestinal disorders with diar¬ 
rhea and vomiting. According to 
Dujardin-Beaumetz, the dose should 
never exceed % grain (0.02 Gm.) ; 
Huchard gives %2 grain (0.005 Gm.) 
three or four times daily in adults. 

As a remedy for the reduction of 
obesity, adonis aestivalis has proved 
of value. Owing to the fact that it 
does not possess a tendency to cumu¬ 
lation, it may be continued for a long 
time. It is claimed to have been 
effective in relieving the heart from 
an excessive covering of fatty tissue. 
The tincture of this species may be 
given in doses of 10 minims (0.6 c.c.) 
three times daily. 

To reduce the active cerebral 
hyperemia present during a paroxysm 
of epilepsy adonis has been recom¬ 
mended, owing to its power of stimu- 


410 


ADRENALS, DISEASES OF (SAJOUS). 


lating the vasoconstrictors. It may 
be advantageously combined with the 
bromides. 

C. E. DE M. Sajous 

AND 

L. T. DE M. Sajous, 

Philadelphia. 

ADRENALIN.— See Animal Ex¬ 
tracts: Adrenals. 

ADRENALS, DISEASES OF 
THE. —Although it is the purpose of 
this Cyclopedia to present the prevail¬ 
ing or current views upon the subjects 
treated, the writer does not feel that 
he can conscientiously observe this 
rule in the present instance. Having 
probably devoted more time to the 
study of the ductless glands and to a 
comparative analysis of the work done 
by others than any other investigator 
in this comprehensive field, he does 
not hesitate to state that the physio¬ 
logical roles that physiologists now 
attribute to the adrenals are not true 
functions but merely secondary ex¬ 
pressions of a function first described 
by myself in 1903. It is, briefly, that 
the adrenals sustain tissue oxidation 
and metabolism by contributing an 
oxidizing ferment to the hemoglobin. 

What I deem to be only manifesta¬ 
tions of that function, are: (1) Oliver 
and Schafer’s theory that the adrenals 
sustain the cardio-vascular tone; (2) 
Cannon and La Paz’s emergency theory, 
in which the adrenals are thought to 
secrete only under the stress of ex¬ 
citement, fear, anger, etc., and (3) 
Abelous and Langlois’ theory in which 
the adrenals are thought to carry on 
an antitoxic role, mainly for the de¬ 
struction of fatigue wastes. All these 
theories have been severely attacked 
by other physiologists, Stewart, 
Hookins, Gley and others, and it is 


generally considered at present that 
they are obsolete. From my view¬ 
point, however, such is not the case, 
for if, as I hold, the adrenals govern 
respiration and tissue oxidation (a 
function admittedly obscure accord¬ 
ing to physiologists), it is but normal 
that they should sustain the vascular 
tone, secrete abnormally under the 
influence of excitement, and take part 
in breaking down fatigue wastes. 

It has also been shown that adre¬ 
nalin is able in small doses to lower 
the blood-pressure. This is due from 
my viewpoint to the fact that it 
primarily causes constriction of the 
vasa vasorum; the arterial supply of 
the vascular muscularis being re¬ 
duced, the vessels dilate. 

To understand the role of the ad¬ 
renals in disease it is important to 
understand the following:— 

The Adrenal Secretion in Pulmonary 
and Tissue Oxidation.—The prevailing dif¬ 
fusion doctrine as to the absorption of 
oxygen from the pulmonary air and the 
elimination of carbonic acid, having been 
shown by Paul Bert, Muller, Setschenow 
and Holmgren, Bohr and other authorities 
to be defective, Bohr concluded in 1891 
that some internal secretion capable of tak¬ 
ing up the oxygen from the air in the 
lungs was necessary to explain the process. 
A comprehensive study of the question 
led me to the conclusion that it was the 
internal secretion of the adrenals which 
carried on this all important function. The 
following are but a few of the main factors 
in support of this opinion: 

1. The marked affinity of the adrenal secre¬ 
tion for oxygen, sustained by the experi¬ 
mental observations of Vulpian, Cybulski, 
Langlois, Battelli, Abel, Takamine and 
others, including the writer. 

2. The presence of the adrenal secretion 
in the venous blood between the adrenals and 
the pulmonary air cells, sustained by the 
experimental observations of Gottschau, 
Manasse, Aulde, Stilling, Pfaundler, Cybul¬ 
ski and Scymonowicz, Biedl, Langlois, Dreyer, 


ADRENALS, DISEASES OF (SAJOUS). 


411 


Salvioli and Pizzolini and personal ana¬ 
tomical researches. 

3. The marked reducing power of the 
blood coursing in the walls of the air-cells, 
shown by the experiments of li.obin, Verdeil, 
Gamier, and Muller. 

4. The presence in the hemoglobin, of a 
constituent ivhose physicochemical properties 
are those of the adrenal secretion, sustained 
by the observations, first, of Vulpian, Gaut¬ 
ier, Moore, Moore and Purinton, and Cybul- 
ski as to the properties c f the adrenal prin¬ 
ciple; those of Battelli, Dixon and Young as 
to the presence of the adrenal principle in 
the blood; of Mulon as to its presence in the 
red corpuscles; of Schmiedeberg, Jaquet, 
Abelous and Biarnes, and Salkowski, and my 
own as to the presence of an oxidizing fer¬ 
ment in the blood; of Jolles and Poehl as to 
the catalytic and oxidizing properties of the 
adrenal components of the blood. 

5. The adrenalin secretion can endow 
hemoglobin with its oxygen-carrying power 
sustained by the observations of Menten 
and Crile (1915) that the blood of the 
adrenal vein invariably assumed a bright 
red color in from one to twenty minutes 
after dilution with salt solution, while 
blood from other organs treated in the 
same manner showed no change—a fact 
found spectroscopically to be due to an 
increased formation of oxyhemoglobin. 
Again, Menten (1917) having added ad¬ 
renalin to diluted human venous blood, 
found that it caused an increase in the in¬ 
tensity of the oxyhemoglobin absorption 
bands. 

6. The presence of the hemoglobin con¬ 
taining the adrenal principle in all parts of 
the body, including the skin, sustained by the 
presence of melanins everywhere and their 
identity as hemoglobin derivative and as the 
adrenal principle based on the investigations 
of Leonard Hill, Hirschfeld, Chittenden and 
Albro as to melanin being an hemoglobin 
derivative; those of Boinet, Miihlmann, and 
myself as to the identity of melanin (the 
bronze pigment of Addison’s disease) as a 
product of the adrenals. 

7. The marked influence of the adrenal 
secretion and preparations upon the tem¬ 
perature, general oxidation, and metabolism, 
sustained by the observations of Reichert, 
Morel, Lepine, Israel, and others, including 
myself, as to their ability to cause a rise of 


temperature; those of Brown-Sequard and 
many others, as to the steady decline of tem¬ 
perature following removal of the adrenals, 
or occlusion of the adrenal veins; the hypo¬ 
thermia of Addison’s disease; the observa¬ 
tions of Byelavcnty, loteyko, Dessy and 
Grandis, and others, includi..g myself, as to 
the increased gaseous interchanges and cellu¬ 
lar metabolism, and the increase in the 
elimination of waste products caused by the 
adrenal principle. 

The Adrenal Secretion in Immunity.— 

The adrenal secretion in this connection is, 
from my viewpoint, but one of the antibodies 
which carry on this process, being what has 
been termed by Bordet the “fixative” or 
“specific immunizing body” and by Ehrlich 
“amboceptor.” Referring to “Internal Se¬ 
cretions” for details which cannot be em¬ 
bodied here, upon this phase of the question, 
1 will limit myself to the direct relationship 
of the adrenals with the autoprotective 
functions:— 

The adrenals are known to carry on anti¬ 
toxic functions. Sustained by the observa¬ 
tions of Albanese (1872), which showed that 
removal of the adrenals reduced the resist¬ 
ance to poisoning by neurine; those of Abel¬ 
ous and Langlois (1892-1898), which showed 
that the adrenals neutralized poisonous sub¬ 
stances derived from muscular activity and 
bacterial products, and also by the investiga¬ 
tions of Mosse. Additional testimony is 
afforded by the marked evidences of over¬ 
activity shown by the adrenals under the 
influence of certain waste products and tox¬ 
ins, as noted by Langlois and Charrin, Petit, 
Stilling, Auld, Wybaux, and others, and also 
by the protection afforded by adrenalin in¬ 
jections against strychnine injections ob¬ 
served by Oppenheim, Meltzer and Auer and 
various toxemias and infections as observed 
by Hoddick, Netter, Marran and Dare, 
Moizard, Kirchheimer, and many other 
clinicians. 

The relationship between the adrenals and 
general oxidation, shown above, also estab¬ 
lishes a connection with the production of 
fever, which, in the light of modern work is 
also considered, up to a certain limit, as a 
defensive process. C. E. de M. S.] 

To disregard functions of such im¬ 
portance would make it impossible to 
account for many phenomena awak- 


412 


ADRENALS, DISEASES OF (SAJOUS). 


ened by disorders of the adrenals, and 
correspondingly limit our usefulness in 
the practical field. This entails, how¬ 
ever, the necessity of granting to the 
adrenals a position in pathology equal 
to any of the major organs. Indeed, 
the functions I have attributed to them, 
in addition to those with which they are 
already credited, entitle them to rank 
pathogenically with the heart and blood¬ 
vessels in so far as the general vascular 
pressure is concerned, and the lungs in 
respect to respiration and tissue oxida¬ 
tion. 

When, moreover, their role in the 
autodefensive or immunizing proc¬ 
esses of the body is also taken into ac¬ 
count, their importance may almost be 
said to exceed that of other organs; 
since they thus not only serve to sustain 
life through tissue oxidation, but also to 
protect life through their role in im¬ 
munity. 

CLASSIFICATION. —Impairment 
of these functions to any extent, 
through factors which either inhibit or 
exaggerate the secretory activity of the 
adrenals, must necessarily awaken 
symptoms which indicate the functional 
disorders present. In Addison’s disease 
(treated by Prof. Langlois, of Paris,' 
earlier in the present volume), for 
example, where destruction of the ad¬ 
renals or of their secretory nerves by 
a local lesion correspondingly compro¬ 
mises their functions, we have as main 
phenomena not only the vascular hypo¬ 
tension and cardiac weakness which the 
well-known action of the adrenal secre¬ 
tion on the blood-pressure explains, but 
also the low temperature, the general 
coldness, the dyspnea and the gradual 
emaciation which deficient oxidation 
alone accounts for. Now if, from any 
cause, the functions of the adrenals are 
inhibited, we have a reproduction, more 


or less marked according to the degree 
of inhibition, of these morbid phenom¬ 
ena. They form the symptom-complex 
of the condition best designated by the 
term “hypoadrenia.” 

[This term was selected owing to its 
greater exactness and brevity than “hypoad- 
renalism,” and owing to the fact that the 
latter suggests the presence of a habit such 
as “alcoholism.” It is obviously less cum¬ 
bersome than “insufficiency of the adrenals” 
or “adrenal insufficiency,” and corresponds 
with terms in current use such as “anemia,” 
“asthenia,” etc. 

In 1899 Sergent and Bernard (Archives 
Generales de Medecine, July) were the first 
to advance the view that adrenal insufficiency 
was a syndrome due to destruction of the 
adrenals, but standing apart from Addison’s 
disease, which they ascribed mainly to lesions 
of the abdominal sympathetic. My own re¬ 
searches (“Internal Secretions,” vol. i, 1903. 
and ii, 1907) sustained the opinion of many 
other observers, however, to the effect that 
the elimination of Addison’s disease was not 
warranted, and that this disease presented the 
most comprehensive external picture of grad¬ 
ual destruction of the adrenals or of the 
periadrenal sympathetic structures, or of 
these structures and the adrenals jointly, i.e., 
of adrenal insufficiency. 

Again, Sergent and Bernard ascribe the 
syndrome of adrenal insufficiency as a whole 
to a general intoxication which they divide 
into fulminant (sudden death), acute (rapid 
autointoxication), and subacute (slow auto¬ 
intoxication). From my viewpoint, however, 
all the symptoms excepting the convulsions 
are due to the inhibition of functions which 
are primarily dependent upon the adrenals: 
viz., general oxygenation, metabolism, and 
nutrition. The only intoxication phenomena, 
the convulsions witnessed in these cases, I 
ascribe to the accumulation of toxic wastes 
(shown by Abelous and Langlois to be an¬ 
tagonized by the adrenal secretion) which 
are not broken down with sufficient rapidity 
when the oxidation processes sustained by 
the adrenals are inhibited. C. E. de M. S.] 

Of the various forms of hypoadrenia 
is one which is practically unrecognized, 
though frequently a cause of death’ 
mainly among children, viz.:— 


ADRENALS, DISEASES OF (SAJOUS). 


413 


TERMINAL HYPOADRENIA. 
DEFINITION. —Terminal hypoad- 
renia is a form of marked asthenia 
which occurs late in the course of an 
acute febrile disease as a result of ex¬ 
hausting secretory activity of the ad¬ 
renals—acting as defensive organs—in 
the course of that disease. 

[The term “terminal” is ‘ serted here be¬ 
cause it is important to differentiate this 
form of hypoadrenia from that which occurs 
early in the course of a toxemia and known 
as adrenal hemorrhage, treated farther on in 
this article. C. E, de M. S.] 

PATHOGENESIS AND SYMP¬ 
TOMATOLOGY.— The adrenals be¬ 
ing admittedly concerned in the protec¬ 
tion of the organism during infections 
and intoxications, by contributing an 
excess of their secretion during the 
febrile stage of the disease (sometimes 
considerably prolonged),it follows that, 
after this stage is over, the adrenals 
should lapse into a condition of more 
or less temporary insufficiency through 
fatigue or exhaustion. That other or¬ 
gans concerned in the immunizing pro¬ 
cess are influenced in the same way 
must doubtless be the case, but the fact 
remains that it is the symptomatology 
of hypoadrenia that is uppermost. 

In lobar pneumonia and broncho¬ 
pneumonia, for instance, resolution may 
be considerably delayed and convales¬ 
cence likewise. There is, late in the 
case, extreme adynamia and a low 
blood-pressure, the temperature is below 
normal, the pulse weak and more or less 
rapid, and death from heart-failure is 
not infrequent. In typhoid fever, hypo¬ 
adrenia is commonly observed. The 
disease assumes what is now known as 
the cardiac type, with, late in the case, 
extreme prostration, a rapid, weak and 
sometimes irregular pulse, hypothermia, 
and a marked tendency to vertigo, faint¬ 
ing, and cardiac failure. 


[Sicard (Bull, de la soc. med., July 21, 
1904) reported the case of a young woman 
in whom the foregoing symptoms appeared 
on the ninth day of a bronchopneumonia. 
Extreme muscular weakness, marked hypo¬ 
thermia and low blood-pressure, diarrhea, 
and Sergent’s white line, which denotes 
marked adrenal insufficiency, were present. 
On the fifteenth day the blood-pressure fell 
to 70 or 80 (7 or 8 per cent, potain) and 
death followed three days later. At the 
autopsy the adrenals were found hemor¬ 
rhagic. This suggests that adrenal lesions 
may be present in all such cases. Yet, 
Ribadeau-Dumas and Bing (Bull, de la soc. 
anat., June 3, 1904) have witnessed the 
same symptoms in cases of measles which 
recovered, while Bossuet (Gaz. hebd. des 
sci. med. de Bordeaux, Oct. 30, 1904) refers 
to 8 cases in various febrile disorders in 
which typical symptoms of adrenal insuffi¬ 
ciency, asthenia, low blood-pressure, etc., 
developed suddenly and disappeared spon¬ 
taneously, aided perhaps by adrenal extract 
which had been administered. 

As stated recently by Morichau-Beauchant 
(Le progres medical, Oct. 9, 1909), the ad¬ 
renals seem to show a special predilection 
for certain infections. Diphtheria easily 
leads them all in this connection. So seri¬ 
ously do these organs suffer in these cases 
that Sevestre and Marfan have termed the 
type “secondary syndrome of malignant 
diphtheria.” Hutinel ascribes the fulminat¬ 
ing cases of scarlatina to this cause. Tet¬ 
anus, erysipelas, mumps, certain forms of 
tonsillitis, and certain streptococcic infec¬ 
tions may also present the typical syndrome 
of hypoadrenia. Goldzicher (Wiener klin. 
Woch., June 10, 1910) was led by his re¬ 
searches to conclude that in the various 
forms of septicemia the appearance of lower 
blood-pressure was to be ascribed to in¬ 
sufficiency of the adrenals. C. E. de M. S.] 

When, at the end of an infectious 
disease, the case, instead of proceeding 
to convalescence, remains in a condition 
of asthenia, with low blood-pressure 
and temperature, there is good ground 
for the conclusion that terminal hypo¬ 
adrenia has occurred. Exhaustion of 
the adrenals during the acute process 
having inhibited the secretory activity 


414 


ADRENALS, DISEASES OF (SAJOUS). 


of these organs, the above symptoms 
result from inadequate oxidation of, 
and metabolic activity in, the tissues. 
Sergent’s white line, brought about by 
gently rubbing a narrow streak over 
any part of the abdomen with the finger, 
may be obtained in the majority of these 
cases. After a short period the area 
becomes whitish and remains so a short 
time. 

The writers found the white line 
present in 145 out of 228 cases; 65 of 
these had hypotension and 80 a nor¬ 
mal or hypertension. The 83 cases 
which did not give the test included 
30 with hypotension and 53 with nor¬ 
mal or hypertension. The 80 cases 
with the white line without hypoten¬ 
sion and 30 with hypotension with¬ 
out the white line make a total of 
110, or one-half of the 228 cases 
tested, which do not conform to the 
rule. They conclude that the white 
line cannot, therefore, constitute a 
sign of either adrenal insufficiency or 
hypotension. Lautier and Gregoire 
(Soc. de biol., vol, Ixvii, p. 690, 1910), 

In a special research for the pres- 
. ence or absence of Sergent’s white 
line in 100 sick or wounded soldiers 
in a garrison infirmary, the line was 
elicited in 81, It was present in all 
but 2 febrile cases and in 17 out of 
20 subjects with gonorrhea. It was 
never absent in grip, rheumatism, 
malaria, or tuberculosis, and was en¬ 
countered in a variety of purely local 
conditions, as gingivitis and orchitis. 
The writer concludes that the white 
line is of great value in certain emer¬ 
gencies of differential diagnosis, as 
when acute adrenal insufficiency is con¬ 
fused with a pyrexia of meningeal, 
thoracic, or abdominal origin. Its 
association with certain infections 
like grip and rheumatism means a 
certain degree of asthenia and hypo¬ 
tension, and betrays the implication 
of the adrenals in the disease picture, 
though not as serious as acute ad¬ 
renal insufficiency, with collapse, and 
does not carry a bad prognosis. 
Finally, when encountered in associa¬ 


tion with some trivial local condition, 
it represents a mere coincidence, 
or is due to a transitory disturbance 
of vasomotor equilibrium. Baudron 
(Jour, de med. et de chin prat., July 
25, 1918). 

The patient complains of cHtlliness; 
the surface is pale, owing to the poverty 
of the blood in cellular elements and 
hemoglobin, and to recession of the 
blood-mass from the surface to the 
deeper vascular trunks. The vascular 
tension being low, the pulse is rapid and 
the heart-beat weak. Anorexia, due to 
deficient metabolism and diminished de¬ 
mand for food, nausea, the result of re¬ 
laxation of the gastric muscular coat, 
and diarrhea, due to a similar condition 
of the muscular coat of the already pas¬ 
sively engorged intestine, and more or 
less frequent fainting spells, are all con¬ 
comitant symptoms that may be wit¬ 
nessed in such cases, which are always 
greatly exposed to relapse or to sudden 
death from heart-failure. 

The author has observed nine cases 
of acute suprarenal insufficiency of 
variable intensity, ending in recovery. 
The symptoms develop very rapidly, 
and, besides, they can disappear spon¬ 
taneously, at the same time with the 
illness which they accompany, for this 
acute adrenal insufficiency is due to an 
infection or an intoxication. The writer 
has always noted that the insufficiency 
occurs in the course of a toxic or infec¬ 
tious malady, medical or surgical. 
G. Bossuet (Gaz. hebd. des Sci. Med. 
de Bordeaux, Oct. 30, 1904). 

Case of acute insufficiency of the 
adrenals in an apparently healthy 
farmer who had been doing some 
hard work, exposed to the sun for 
several hours, when suddenly he col¬ 
lapsed with intense abdominal pain 
and headache, with great prostration. 
On the presumptive diagnosis of sun¬ 
stroke, he was treated with cold to 
the head and purgatives, but the 
symptoms persisted, soon accompa¬ 
nied by vomiting and hiccough; the 


ADRENALS, DISEASES OF (SAJOUS). 


415 


prostration increased, with a ten¬ 
dency to stupor; there were intense 
headache and delirium, respiration 
was superficial, the pupils were di¬ 
lated and did not react to stimuli, the 
heart-sounds became faint and death 
occurred at the end of the week. The 
only pathological findings at autopsy 
were atrophy of the adrenals from a 
sclerotic process in the veins, and 
compression from a hematoma from 
rupture of one of the veins in the 
adipose tissue surrounding the left 
suprarenal capsule. The writer at¬ 
tributes the acute insufficiency in his 
case to excessive exposure to the 
heat of the sun. Sotti (Policlinico, 
Jan. XV, Med. Sec. No. 1, 1908). 

Symptoms arising in the course of 
scarlatina which are very suggestive 
of insufficiency of the suprarenals. 
The symptoms are asthenia, depres¬ 
sion, failure of the heart-power, hypo¬ 
tension of the arteries, tendency to 
syncope, abdominal pains, and a 
brown coloration of the skin. The 
use of small doses of adrenalin had 
a remarkable effect in the cases cited, 
the patient recovering after being in 
an apparently desperate condition. 
V. Hutinel (Le bull, med.; Med. 
Record, Sept. 18, 1909). 

The 2 most prominent symptoms 
of terminal hypoadrenia in typhoid 
fever, acute nephritis, pneumonia, 
scarlet fever, and diphtheria, noted by 
the writers, were a sudden fall of 
blood-pressure and extreme prostra¬ 
tion but hypothermia, vomiting, a 
profuse green diarrhea, and an ery¬ 
thematous rash were also commonly 
observed. The adrenal lesions were 
found to differ, l>eing either hemor¬ 
rhagic, or granulofatty, and ending in 
necrosis. Dumas and Hervier (Bull, 
et mem. de la Societe med. des Hop. 
de Paris, 1913). 

The symptomatology of the term¬ 
inal hypoadrenia in the various in¬ 
fections, measles, diphtheria, erysipelas, 
scarlet fever and others, is virtually 
identical in all, asthenia, low blood- 
pressure, prostration, hypothermia, 
vomiting, pain in the epigastrium, 
though two or more of these symp¬ 


toms may dominate the picture. 
Daily doses of 12 to 20 minims of 
adrenalin daily in such cases, cause 
the disease to lose its menacing char¬ 
acter as regards cardiac arrest. V. 
Hutinel (Arch, de Med. des Enfants., 
March, 1915). 

The writers observed 3 cases of 
sudden death from pernicious malarial 
fever in soldiers. In all 3 cases 
there was hypotension coinciding 
with maintenance of regular cardiac 
rhythm. In 1 of the cases the supra¬ 
renal white line pointed out by Ser- 
gent was clearly identified. In all 3 
cases there were found lesions of the 
adrenal cortex. Paisseau and Le- 
maire (Acad, de Med., Oct. 17, 1916; 
Monde Med., Jan., 1917). 

The adrenals are frequently in¬ 
volved in camp diseases, including 
dysentery, malaria and gas gangrene, 
and the writer reports a case of 
anthrax septicemia in which cardio¬ 
vascular disturl)ances were pro¬ 
nounced from the first. The young 
man suffered from intense pain in the 
epigastrium, with profuse vomiting 
and final hematemesis, evidently due 
to elimination of the microbes or 
their toxins by the gastro-intestinal 
mucosa. The extremely low blood- 
pressure and imperceptible pulse 
were explained by the necropsy find¬ 
ings of edema of the anterior medias¬ 
tinum, compressing the pericardium, 
and destruction of the left supra¬ 
renal by a recent hemorrhage. Roger 
(Paris med., July 14, 1917). 

Complications of various kinds may 
occur. The immunizing processes be¬ 
ing greatly weakened through the defi¬ 
ciency of adrenal secretion, one of its 
important factors, septic infection, ab¬ 
scesses, bone lesions, tuberculosis of a 
rapid type, and other infections may 
more or less rapidly develop. Disorders 
of nutrition, cholelithiasis, and occa¬ 
sionally Addison’s disease may also 
appear. In acute pulmonary infections, 
pneumonia, for example, organs in the 
neighborhood of the focus of infection^ 


416 


ADRENALS, DISEASES OF (SAJOUS). 


the pleura, the mediastinal glands, etc., 
being inadequately protected by the 
blood or its phagocytic cells, become 
the prey of specific bacteria. Briefly, 
the body is rendered vulnerable to 
the attacks of almost any pathogenic 
organism. 

PATHOLOGY. —In the special 
type in question no adrenal lesion may 
be discernible. In the majority of in¬ 
stances, however, the organs are en¬ 
larged and congested and may show, 
here and there, a limited hemorrhagic 
area. Their appearance suggests not 
only the functional torpor incident upon 
functional exhaustion, but the presence 
of a passive congestion resulting from 
loss of resiliency of their sinusoidal ves¬ 
sels, thus impeding the circulation 
through them. Occasionally they are 
the seat of suppuration, a complica¬ 
tion which is apt to be observed when 
the causative disease is, or includes, a 
streptococcic infection, pneumonia, or 
meningitis. 

The pathological picture of the more 
severe form of adrenal complications, 
i.e., intercurrent hypcradrenia, shows 
far more distinct lesions of the adrenal 
parenchyma. Hence the typical lethal 
phenomena that attend many of these 
cases. 

Mott and Halliburton have found 
already that in cases of death from 
exhausting diseases the adrenalin 
present in the adrenals was dimin¬ 
ished or absent. The writers have 
extended these observations; they 
have examined the adrenals in the 
cases of 50 adults dying from various 
diseases. The glands were placed in 
Cohn’s fluid for twenty-four hours 
and afterward stained with Schar- 
lach or Sudan III; by this method 
the chromaffinic substance and the 
fat were demonstrated. They relied 
upon this demonstration of the 
amount of chromaffinic granules in 
the cells of the medulla, and did not 


carry out the physiological test. No 
appreciable loss of the substance oc¬ 
curred during twenty-four hours fol¬ 
lowing death, as told by control ex¬ 
periments in animals. Adrenalin was 
always being given off, especially if 
the splanchnics were stimulated. The 
conclusions drawn from, their work 
were that in cases of acute infection 
and rapid death adrenalin was absent 
in the medulla; this applied also to 
cases of death from shock and from 
peritonitis when, in short, the blood- 
pressure was low. On the contrary, 
in chronic diseases, such as phthisis, 
adrenalin was to be found in the me¬ 
dulla. In cases of high blood-pres¬ 
sure adrenalin was present and dis¬ 
tinctly increased. F. A. Bainbridge 
and P. R. Parkinson (Brit. Med. 
Jour., Mar. 11, 1907). 

In 25 experiments on guinea-pigs and 
hedgehogs, the writer found that in 
only three was the microscopic condi¬ 
tion of the adrenals approximately nor¬ 
mal, while in the remaining 22 very 
characteristic changes were present, 
which in 18 were of serious degree, con¬ 
sisting of hemorrhages and necroses, 
alone or combined, after poisoning with 
the diphtheria toxin. Strubell (Berl. 
klin. Woch., March 21, 1910). 

The influence of diphtheria toxins 
upon the secretory activity of the ad¬ 
renals is well shown by personal ex¬ 
periments in which poisoning of an 
animal with diphtheria toxin was 
found to cause, at first, an increased 
proportion of adrenalin in the blood 
and subsequently a gradual decrease 
until total disappearance of the ad¬ 
renal principle had occurred. Tsche- 
boksaroff (Berl. klin. Woch., June, 
1911). 

The writer convinced him that 
these organs are invariably the seat 
of lesions, and that the gravity of the 
latter depends more upon the inten¬ 
sity of the attack than upon its dura¬ 
tion or associated infections. Molts- 
chanow (Rev. del Circ. Med. Argen- 
tino, Nov.-Dee., 1912). 

The writers found that acute peri- 
tonitis showed a very marked reduc¬ 
tion of adrenalin, and that in 50 per 


417 


ADRENALS, DISEASES OF (SAJOUS). 


cent, of the cases of this disease 
examined post mortem, the adrenal 
cortex showed marked histological 
lesions. The authors conclude that 
acute peritonitis takes the lead among 
infections in the production of ad¬ 
renal lesions, a fact which explains 
the circulatory failure so marked in 
this disease. Reich and Beresnogow- 
ski (Beitr. zur klin. Chirurgie, May, 
1914). 

TREATMENT. —In these particu¬ 
lar cases the use of adrenal gland, or 
of pituitary body, which acts very simi¬ 
larly but with less violence and more 
lasting effects, sometimes gives surpris¬ 
ing results. The adrenal product— 
which, from my viewpoint, is also the 
main active agent in the neural lobe of 
the pituitary, as shown by the chromaf¬ 
fin test—supplies precisely what the 
body needs, e.g., the resumption of all 
oxidation processes (thus restoring gen¬ 
eral metabolism and nutrition), and a 
rise of blood-pressure, which causes the 
blood to circulate normally in all organs, 
including the skin and the adrenals 
themselves. Indirect effects are also 
obtained: its action on the heart in¬ 
creases the contractile power of this 
organ, which is thus rendered capable 
of projecting the blood with more vigor 
through the lungs, and causes oxygena¬ 
tion of the blood to become more per¬ 
fect. Recovery is also materially aided 
by the rise of blood-pressure that the 
adrenal product insures, causing, as it 
does, arterial blood to be driven from 
the splanchnic area toward the periph¬ 
eral organs, including the lungs and 
the brain. From these features alone 
considerable benefit is derived. 

If we recall, moreover, the participa¬ 
tion of the adrenal secretion (which the 
adrenal preparation administered repre¬ 
sents) in the immunizing process, we 
have the added factors of ridding the 

blood of any intermediate—and there- 

1 - 


fore toxic—wastes, bacterial toxins, 
etc., it may contain, and of increasing 
phagocytic activity, thus antagonizing 
efficiently any pathogenic organism that 
may remain to compromise the issue. 

Thus explained, we can understand 
the phrase, “little short of marvelous,” 
applied to the results obtained by some 
clinicians. We can also understand the 
marked reduction in the mortality ob¬ 
tained by Floddick (Zentralbl. f. Chir., 
Oct. 12, 1907) in cases of peritonitis 
following appendicitis accompanied by 
uncontrollable decline of the blood- 
pressure, cyanosis, and other evidences 
of collapse, and also in puerperal toxe¬ 
mias, by the slow intravenous use of ad¬ 
renalin in saline solution. Hoddick as¬ 
cribes the lowering of the blood-press¬ 
ure to paralysis of the vasomotor cen¬ 
ter; but as the toxemia is the cause of 
this condition, an agent capable of coun¬ 
teracting both cause and effect is neces¬ 
sary. This is met by the adrenal prin¬ 
ciple. Josue (Soc. Med. des Hopitaux, 
May 21, 1909), in typhoid fever, like¬ 
wise relieved threatening symptoms by 
injecting 15 minims (1 c.c.) of adrena¬ 
lin (1:1000 sol.) in % to 1 pint (250 
to 500 c.c.) of physiological saline solu¬ 
tion subcutaneously. The influence of 
the saline solution in these cases must 
not be overlooked, however. Eight 
years ago I urged that death was often 
due, in infectious and septic diseases, to 
the fact that the osmotic properties of 
the blood became deficient, and advised 
the use of saline solution from the onset 
of the disease. The reduction in the 
mortality of pneumonia in the practice 
of men who have carried out this sug¬ 
gestion has demonstrated its value. 

[Several clinicians have employed much 
larger doses of the adrenal active prin¬ 
ciple with profit. Marran and Darre (Jour, 
des praticiens, May 15, 1909) found it of 
great value in the collapse of diphtheria 
•27 


418 


ADRENALS, DISEASES OF (SAJOUS). 


with marked asthenia, low blood-pressure, 
and subnormal temperature. Moizard (Re¬ 
vue de therap., Jan. 1, 1910) recommends ad¬ 
renal organotherapy as soon as asthenia and 
low blood-pressure occur in any infection. 
He gives daily two sheep’s fresh adrenals, 
finely divided and mixed with powdered 
sugar, or administers the active principle, 10 
to 20 drops daily divided in five or six doses. 
Kirchheimer (Miinch. med. Woch., Dec. 20, 
1910) has found large doses, 10 to 24 min¬ 
ims, safe hypodermically in the collapse of 
pneumonia, diphtheria, and scarlet fever. 
Letulle has found it of great value in the 
latter disease. The better plan, from my 
viewpoint, is to inject it with saline solution 
(at 108° F.), intravenously, the needle of the 
syringe containing the adrenalin being in¬ 
serted into the rubber tube of the saline 
solution apparatus. C. E. de M. S.] 

If adrenal insufficiency arises during 
the progress of diphtheria, the writer 
advises combining suprarenal opother¬ 
apy with serotherapy. If syphilis is 
also present, suprarenal opotherapy may 
be associated with mercurial treatment. 
In the other infectious diseases, where 
no specific medication exists, opotherapy 
should be begun from the beginning of 
the symptoms of suprarenal insuffi¬ 
ciency. Adrenalin may be given by the 
mouth, or, if the hypodermic method is 
used, 1 c.c. of a 1:1000 solution is 
added to 50 grams of normal salt solu¬ 
tion and injected into the subcutaneous 
tissue. As this medication is inoffen¬ 
sive, it can be continued daily until the 
accidents of suprarenal insufficiency 
have disappeared. Comby (Archives 
de med. des enfants, Jan., 1911). 

To ascertain the most efficient 
dosage of adrenalin to counteract 
cardiovascular failure in pneumonia, 
typhoid and paratyphoid fever, the 
writer compared the effects of vari¬ 
ous doses in 30 patients. She found 
that 0.5 c.c. (8 minims) of adrenalin 
caused a moderate rise of blood-pres¬ 
sure which could be sustained by re¬ 
peating the dose hypodermically 
every hour or hour and a half. This 
dose was found to be the most effi¬ 
cient for infectious diseases. Mans- 
vetova (Roussky Vratch, July 4, 
1914). 


The writer calls attention to the 
morbid effects of the hardships of 
the European War as causes of hy- 
poadrenia, through traumatic shock, 
major injuries, typhoid fever, typhus, 
cholereiform diarrhea, Asiatic chol¬ 
era, chloroform anesthesia, exhaus¬ 
tion, etc. Such cases are not met by 
10 to 15 drops of adrenalin 1:1000 
solution. He gives %o to grain 
(2 to 3 milligrams) divided into 4 to 
6 doses hypodermically, and in addi¬ 
tion to grain (1 to 2 milli¬ 
grams) orally. He is convinced of 
having successfully combated col¬ 
lapse with such doses which other¬ 
wise would have ended fatally. Ser- 
gent (Bulletin de I’Acad. de Med., 
Sept. 7, 1915). 

In the hypoadrenia of pneumonia, 
diphtheria, and typhoid fever, the 
writer found a combination of 
pituitrin and adrenalin, 0.25 c.c. (4 
minims) of the former, and 0.5 c.c. 
(8 minims) of the latter, intraven¬ 
ously in young children and twice 
these doses in older children restored 
failing circulation more actively than 
all other agents. This confirmed the 
results of Kepinow, who had pre¬ 
viously urged this combination. Roh¬ 
mer (Miinch. med. Woch., June 16, 
1914). 

The essential symptomatic triad of 
adrenal insufficiency in asthenia, is low 
blood-pressure, and Sergent’s white 
line. In some cases adrenal insuffi¬ 
ciency constitutes the entire clinical 
picture and seems primaryj yet often 
close examination reveals a causative 
infection, at times very slight, e.g., 
a mild throat inflammation or intes¬ 
tinal infection. Other forms com¬ 
prise the adrenal overstrain of soldiers; 
the adrenal insufficiency of infections, 
such as typhoid, diphtheria, and tuber¬ 
culosis; that due to alimentary or other 
forms of intoxication; that of cardiac 
dilatation. The solar syndrome (skin 
discoloration and lumbar pains), the 
latter due to involvement of the peri- 
capsular nerve ganglia, may also be 
present. In such cases, extracts of 
the total gland sometimes prove dis¬ 
tinctly superior to the pure adrenalin 


ADRENALS, DISEASES OF (SAJOUS). 


419 


otherwise used. Both these products, 
repeatedly given, exert a regenerat¬ 
ing action on the adrenals. Their 
hypodermic and oral administration 
is free from the danger of causing 
arterial atheroma. Adrenalin by 
mouth gives good results provided it 
is used in sufficient amounts—1 to 4 
and even 5 c.c. (16 minims to 1 or 1J4 
drams) of the 1: 1000 solution a day, 
divided into two intervals. Three c.c. 
(48 minims) may be thus given daily 
for a month or more without harm. 
For hypodermic use the dose is 0.5 
to 2 c.c. (8 to 32 minims) a day, 0.5 
c.c. being preferably not exceeded as 
the single dose. Such injections are 
generally more or less painful. Slow 
absorption of adrenalin is secured by 
injecting under the skin 250 to 500 
c.c. (Fa to 1 pint) of normal saline 
solution to which 1 c.c. (16 minims) 
of adrenalin solution has just been 
added. The skin is usually blanched 
at the point of injection and the ad¬ 
renalin is only with extreme slowness 
absorbed through the contracted ves¬ 
sels. The pain attending this pro¬ 
cedure is prevented by adding 0.01 
Gm. (Vg grain) of novocaine to the 
solution. The injections may be con¬ 
tinued for several days. Extracts of 
the whole adrenal may be given 
orally in daily amounts of 0.2 to 0.4 
Gm. (3 to 6 grains), divided into 0.1- 
to 0.2- Gm. (VA to 3 grains) doses, 
or hypodermically in a daily amount 
of 0.1 Gm. (V /2 grains). Josue (Paris 
med., Jan. 6, 1917). 

Adrenal insufficiency is a rather 
frequent complication of amebic 
dysentery, manifested in marked gen¬ 
eral depression, asthenia, a feeble 
pulse, etc. In the case of a soldier on 
the Franco-Belgian front, stationed 
where Senegalese and Moroccan 
troops had recently been, the onset 
of diarrhea was accompanied by 
prostration and tachycardia. Careful 
examination revealed no organic dis¬ 
turbance save in the liver, which was 
slightly tender and distinctly en¬ 
larged. The number of stools rose 
as high as 45 in 24 hours. The white 
line phenomenon was elicited on the 


abdomen and the pulse remained 
thready at 120 a minute. The dias¬ 
tolic blood-pressure descended to 70 
mm, Hg. (Pachon instrument). Eme¬ 
tine hydrochloride in divided doses, 
to the total amount of 0.06 up to 0.1 
Gm. (1 to 1^2 grains) per diem, to¬ 
gether with adrenaline and camphor¬ 
ated oil, within a few days placed the 
patient on the road to recovery. The 
use of adrenaline is especially recom¬ 
mended where there are signs, even 
slight, of impairment of the adrenals 
due to toxic action of the amebae on 
these organs. R. Dujarric de la 
Riviere and Villerval (Paris med., 
Apr. 21, 1917). 

Case in which there was unusually 
marked pigmentation, disappearance 
of the pigmentation followed supra¬ 
renal treatment. The loss of mus¬ 
cular strength, due to suprarenal de¬ 
ficiency, was very marked. Osborne 
(Amer. Jour. Med. Sci., Aug., 1918). 

These measures are only indicated in 
emergency cases, however. In the 
average case the glandulae suprarenales 
siccae of the United States Pharmaco¬ 
peia, administered by the mouth, is fully 
as effective if a good preparation is 
obtained as soon as asthenia and low 
blood-pressure appear. The powder in 
3-grain (0.2 Gm.) doses, three times 
daily, in capsules, gradually increased 
until 5 grains are given at each dose, 
usually’ suffices. When the cardiac 
adynamia disappears, a small dose of 
thyroid, the desiccated gland, % grain 
(0.03 Gm.J ; strychnine, %o gi*ain 
(0.001 Gm.), and Blaud’s pill, 1 grain 
(0.06 Gm.), added to each capsule, 
greatly hasten convalescence. The iron 
and the adrenal product serve jointly to 
build up the hemoglobin molecule, a 
slow process when left to itself. 

For our knowledge of the action of* 
the use of pituitary extracts in infectious 
diseases we are mainly indebted to L. 
Renon and Delille (1907) ; who began 
their use in 1907. In a recent work in 


420 


ADRENALS, DISEASES OF (SAJOUS). 


which the clinical observations of both 
observers are recorded, Delille (“L’Hy- 
pophyse et la medication hypophysaire,” 
1909), referring to grave cases of ty¬ 
phoid fever, states that they showed 
“arterial hypotension, irregularity of 
the pulse (especially the grave forms), 
oliguria, insomnia; while convalescents 
showed asthenia, hypotension, or at least 
‘effort hypotension’ (Oddo and M. 
Achard), paroxysmal or continuous ta¬ 
chycardia”—all, we have seen, symptoms 
of hypoadrenia or adrenal insufficiency. 
They found 1% grains of pituitary ex¬ 
tract (of both lobes) at noon daily ex¬ 
tremely efficient; it counteracted at once 
the depressed arterial tension, produced 
diuresis, counteracted insomnia, and 
greatly improved the general condition. 
Similar effects were observed in diph¬ 
theria and erysipelas. The results in 
pneumonia do not appear to me to war¬ 
rant the use of any adrenal or pituitary 
preparations early in the case, the first 
few days of the disease, when the 
blood-pressure and the fever are high. 
They should be used only zvhen a low 
blood-pressure and other symptoms of 
hypoadrenia are present. The results 
reported by Delille strengthen this 
opinion. In advanced tuberculosis no 
beneficial effect was obtained from this 
treatment. 

ACUTE HYPERADRENIA AND 
ADRENAL HEMORRHAGE.— 

This condition, which may lead to fatal 
hypoadrenia by arresting the functions 
of the adrenals, is generally known un¬ 
der the term of “adrenal hemorrhage.” 
The association with hyperadrenia, i.e., 
excessive functional activity of the ad¬ 
renals, introduced here, is important in 
that it calls attention to the cause of the 
lethal hemorrhage, viz., abnormally high 
temperature and blood-pressure. 


[Just as Av/^oadrenia appears to me to re¬ 
place advantageously “hypoadrenalism” and 
“adrenal insufficiency,” so does “/ly/j^radre- 
nia” seem to convey more exactly excessive 
adrenal activity than “hyperadrenalism,” 
which suggests habitual overactivity, besides 
being less cumbersome than the phase “ex¬ 
cessive secretory activity” and others in gen¬ 
eral use. C. E. deM. S.] 

This disorder is, briefly, the result of 
undue activity of the adrenals. Hyper¬ 
emia of these organs occurs normally. 
i.e.^ physiologically (owing to their par¬ 
ticipation in the autodefensive func¬ 
tions of the body), in the course of 
all febrile infections or intoxications. 
When these toxemias are severe this 
adrenal congestion is increased in pro¬ 
portion—sufficiently so in some in¬ 
stances to cause rupture of the adrenal 
vascular elements, and hemorrhage 
within the organs. An additional cause 
of congestion in the latter is the abnor¬ 
mal rise of blood-pressure which the 
unusual production of adrenal secretion 
entails; all the vessels of the body being 
unduly contracted, the adrenal capilla¬ 
ries, which are deprived of muscular 
elements, are overladen with blood and 
prone, therefore, to rupture. These 
few facts are necessary to elucidate the 
definition of the disorder. 

DEFINITION. —Acute hyperadre¬ 
nia is that condition of the adrenals 
characterized by intense congestion of 
their vessels, which occurs in the course 
of severe febrile infections and certain 
intoxications, and manifested by a high 
blood-pressure, and in infections, also, 
by a high temperature. When this 
congestion exceeds the resistance of the 
adrenal vessels adrenal hemorrhage oc¬ 
curs, causing death when both adrenals 
are hemorrhagic, in a large proportion 
of cases, especially infancy and child¬ 
hood. 

[The limitation “certain intoxications” is 
introduced, because active congestion of the 


ADRENALS, DISEASES OF (SAJOUS). 


. 421 


adrenals is produced only by poisons which 
cause a marked rise of the blood-pressure, 
strychnine and quinine, for example. As 
shown in “Internal Secretions” (vol. i, pages 
19 to 55, 4th edition, 1911), the use of such 
remedies in the course of infections and in¬ 
toxications may do harm by increasing the 
congestion of the adrenals and therefore the 
chances of hemorrhage. C. E. de M. S.] 

SYMPTOMATOLOGY AND 
PATHOGENESIS.— This disorder is 
relatively common in children, especially 
in infants; death occurs, from adrenal 
hemorrhage, without premonitory symp¬ 
toms, except, -perhaps, a hemorrhagic 
rash or purpura—denoting excessive 
vascular tension—over the body, and a 
high temperature. The toxemia here 
has promptly destroyed the adrenals. 
As a rule, however, more or less marked 
phenomena, beside those due to the dis¬ 
ease from which the child may be suf¬ 
fering, and varying considerably with 
each case, initiate this acute phase of 
the process, the adrenals being on the 
border-line of hemorrhage. These may 
include vomiting and diarrhea, melena, 
very acute abdominal pain, hemateme- 
sis, icterus, fever, with hyperpyrexia 
sometimes immediately before the ad¬ 
renal rupture. When the hemorrhage 
occurs there is more or less sudden col¬ 
lapse, a very feeble and rapid pulse, 
shallow respiration and, perhaps, some 
bronchial rhonchi, the face being more 
or less dusky, cyanosed, or even livid, 
and the temperature subnormal. These 
phenomena are typical of adrenal insuf¬ 
ficiency or failure, the adrenal secretion 
sustaining, we have seen, general oxy¬ 
genation and metabolism and cardio¬ 
vascular contractility. 

Symptomatology of adrenal hemor¬ 
rhage as observed in 80 cases: (1) In 
46 out of 79 cases there were no appre¬ 
ciable signs. (2) In 5 cases there was 
a voluminous hematoma or abdominal 
tumor that could be perceived by pal¬ 


pation. The diagnosis was made in 
1 case “only during life. (3) There 
were peritoneal symptoms in 6 cases, 
all accompanied by tearing of the cap¬ 
sule with hemorrhage. (4) There were 
symptoms of capsular insufficiency in 8 
cases. (5) In 15 cases there was sud¬ 
den death, or death after three days at 
the most, sometimes accompanied by 
delirium, convulsions, contractures, 
coma, hypothermia, and syncope. In 
more than half of the cases, therefore, 
the hemorrhages remain latent and 
apparently without effect upon the 
organism. F. Arnaud (Archives gen. 
de med.. May, 1900). 

Series of four cases of hemorrhage 
into the skin and suprarenal capsules, 
the interesting features of which 
were the sudden onset, rapid course 
and fatal termination. Not one of 
the patients was over a year old. 
The history throws absolutely no 
light on the causation of the disease; 
neither does the question of food ap¬ 
pear to bear any relation to it. The 
presence of hemorrhage in the skin 
and suprarenal capsules would seem 
to make it more probable that the 
disease is some form of toxemia. In 
two cases the blood from the un¬ 
opened heart was examined bacterio- 
logically with negative results. In its 
extremely rapid and fatal termination 
the disease somewhat resembled the 
epidemic diarrhea and vomiting of 
infants. The general condition of the 
patients was different. They did not 
present the sunken eyes and the in¬ 
elastic skin which is frequently met 
with in the epidemic diarrhea, and 
the cyanosis present in these cases is 
very rarely, if ever, seen in the skin 
and suprarenal capsules; the fact that 
Peyer’s patches were much swollen 
is interesting. The authors believe 
that these symptoms are the mani¬ 
festations of a special disease, and 
that the cause of this disease is a 
blood poisoning of some form, at 
present unknown. P. S. Blaker and 
B. E. G. Bailey (Brit. Med. Jour., 
July 13, 1901). 

Three cases of sudden death in in¬ 
fants, due to hemorrhage into the 


422 . 


ADRENALS, DISEASES OF (SAJOUS). 


suprarenal capsules. The train of 
symptoms is very definite. A child, 
previously well, is suddenly seized 
with acute abdominal pain and vom¬ 
iting, the temperature rises, and one 
of the exanthemata is suspected. No 
characteristic rash appears, however, 
though sometimes there is purpura. 
Convulsions supervene, the patient 
becomes moribund, and death occurs 
in a few hours. If the condition is 
an infection presumably, it is a spe¬ 
cial infection of unknown origin. Bac¬ 
teriological examination has proved 
negative in almost every case. Lang- 
mead (Lancet, May 28, 1904). 

The microscopic report was as fol¬ 
lows : The right suprarenal showed no 
abnormal appearances. The left supra¬ 
renal was much broken up, but there 
were the remains of hemorrhage in its 
medullary substance, both in the form 
of extravasated corpuscles and as gran¬ 
ules of pigment. B. G. Morrison (Lan¬ 
cet, June 6, 1908). 

Case of a man 35 years old who suc¬ 
cumbed in five days to adrenal hemor¬ 
rhage. The disturbance was sudden in 
its onset, with symptoms resembling 
those of intestinal obstruction: violent 
abdominal pains, which morphine was 
powerless to relieve, continued vomit¬ 
ing, and absolute retention of gas and 
feces. Laparotomy was performed and 
showed the intestinal tract, including 
the appendix, to be entirely normal. 
The pain was in no way modified by 
operation. The temperature rose to 
39 C. (102.2° F.), the pulse became 
extremely feeble, the respiration slow 
and shallow, and death took place on 
the fourth day after operation. The 
autopsy showed bilateral lesions of the 
adrenals, without other dangers of any 
kind. The left adrenal gave evidence 
of a recent and of a former hemor¬ 
rhage (the patient had experienced a 
similar, though less severe, attack a few 
years before). 

The condition of the abdomen, slow¬ 
ing of the pulse, with temperature re¬ 
maining normal, should draw the atten¬ 
tion from the intestinal tract to the 
adrenals. The case also indicates that 
this syndrome may not be fatal, and. 


if not fatal, may recur. Brodnitz 
(Munch, med. Woch., July 26, 1910). 

In newly born infants suffering 
from erysipelas and other infections, 
the writers observed a syndrome con¬ 
sisting of vomiting, a green diarrhea 
with retraction of the abdomen, an 
erythematous rash, and profound 
asthenia, leading to algid collapse. 
The only lesion found at autopsy in 
such cases was an hemorrhagic dis¬ 
tention of the adrenals. Lesne and 
Francois (Paris Medical, June 29, 
1912). 

Case of an apparently weM boy 
complaining only of slight fatigue, 
who suddenly became comatose, the 
pulse reaching 140 and the tempera¬ 
ture 104° F. (40° C.) and died in 36 
hours. The autopsy showed initial 
typhoid lesions in the intestines and a 
caseous tuberculosis of both adrenals. 
Mery and Heuyer (Paris Med., May 
30, 1914). 

In 1 of 2 cases described, the first, 
occurring in a man 41 years, showed 
as most prominent symptoms a sub¬ 
normal temperature, and slow respi¬ 
ration and pulse. Death followed 3 
days after a nephrectomy for a pyo¬ 
nephrosis. Post-mortem examination 
showed a number of sharply defined 
focal necroses scattered throughout 
the cortical zone of the right adrenal, 
with degeneration of cells, polynu¬ 
clear infiltration, and moderate hemor¬ 
rhage of the gland. Many of the 
capsular vessels were thrombosed, 
so that this thrombosis of the ves¬ 
sels may be a possible cause of the 
adrenal lesions. E. Moschcowitz 
(Proceed. N. Y. Pathol. Soc., Oct- 
Dec., 1917). 

Case suggestive of cerebral hemor¬ 
rhage. The limbs were rigid, the re¬ 
flexes gone, and the pupils distinctly 
dilated. The face and hands were 
cyanosed. The temperature was 
99 F. (37.2° C.). Urine was normal. 

' erebrospinal fluid showed no change 
and gave a negative Wassermann re¬ 
action. The patient died 2j^ hours 
after admission. The clinical course 
was thus apoplectiform in type. The 
necropsy was performed within 2 


ADRENALS, DISEASES OF (SAJOUS). 


423 


hours of death. The only organs ex¬ 
hibiting any marked pathologic change 
were the suprarenals. These were 
almost entirely destroyed, and con¬ 
verted into structureless, amorphous, 
yellowish masses, firm in texture, and 
considerably larger than the original 
glands. W. Boyd (Jour. Labor, and 
Clin. Med., Dec., 1918). 

In adults, most frequently subjects 
between 20 and 30 years of age, the at¬ 
tack may also be sudden, or preceded by 
a period of great lassitude or asthenia. 
In most instances, however, the symp¬ 
toms are such as to suggest acute in¬ 
toxication or infection, with very severe 
pain, either in the epigastrium, the ab¬ 
domen or below the costal margin, as 
the pre-eminent symptom. Then follow, 
in rapid succession, incoercible vomiting 
and, perhaps, diarrhea, and the signs of 
adrenal hemorrhage: great weakness of 
the pulse and rapid decline of the blood- 
pressure, hypothermia, cold sweats, cold¬ 
ness of the extremities, coma and death. 
This, may, however, be preceded by a 
typhoid-like state, delirium, convulsions 
and various perversions of the cuta¬ 
neous pigmentation, varying from yel¬ 
low to light-brown. In a series of 79 
cases collected by Arnaud (19(X)) death 
occurred within a period ranging from 
a few hours to three days. The hemor¬ 
rhage may be due to the rupture of 
a hemorrhagic cyst of the adrenals 
(treated under the next heading) and be 
preceded, therefore, by the symptoms 
peculiar to this condition. 

The types of acute insufficiency of 
the suprarenals are classed by the 
writer as follows: (1) those of sud¬ 
den onset; (2) the asthenic type; (3) 
the nervous type; (4) sudden death 
where nothing but a destructive le¬ 
sion is found; and (5) cases which 
occur in hemorrhagic diseases. These 
types often overlap each other. In 
the asthenic type there is only ex¬ 
treme asthenia, followed in a few 


days by death. The nervous type in¬ 
cludes those showing convulsions, coma, 
delirium, or typhoid states. In instances 
of convulsions the convulsion might 
well be the cause of the adrenal le¬ 
sion. The first type is of particular 
interest because of its striking simi¬ 
larity to acute pancreatitis. The on¬ 
set is sudden, “with epiffastric pain and 
tenderness, vomiting, extreme prostra¬ 
tion, feebleness and rapidity of pulse, 
coldness of extremities, lumbar ten¬ 
derness, and, at times, diarrhea and 
abdominal distention, followed within 
a few days by death.” The shock is 
more profound, the lumbar tender¬ 
ness more acute, and the epigastric 
pain and vomiting less pronounced in 
adrenalitis than is usually the case 
in acute hemorrhagic pancreatitis. 

Attention should be paid to the rela¬ 
tive frequency of the condition in the 
purpuras of childhood and during or 
shortly after the acute infections; 
and due consideration must be paid 
to the apparent insufficiency and in¬ 
flammations in the neighborhood of 
the suprarenals, surface burns, chronic 
heart or pulmonary disease, and any 
phenomenon tending to a great in¬ 
crease in internal blood-pressure. 
Lavenson (Archives of Intern. Med., 
Aug. 15, 1908). 

In “Internal Secretions” (1903-1907) 

I called attention to the fact that many 
drugs influenced the functions of the 
adrenals, some depressing them, others 
overexciting them. When from any 
cause, these organs are debilitated the 
loss of their influence in the defensive 
functions of the body causes it to be 
more easily aflfected both by drugs, tox¬ 
ins, and other poisons. 

Animals with adrenal insufficiency 
are more sensitive to intoxication of 
curare and strychnine than normal 
animals. A large number of poisons 
are more active in decapsulated ani¬ 
mals than in normal ones. Camus 
and Porak (Soc. de Biol., June 21, 
1913). 

Sudden death in a man of 47 after 
20 c.c. (5 drams) of a 2 per cent. 


424 


ADRENALS, DISEASES OF (SAJOUS). 


solution of alypin had been injected 
into the bladder. The only lesion 
found was an extensive tuberculous 
process in the right adrenal. The 
writer cites 3 cases from literature in 
which death followed at once after 
local anesthesia with cocaine or novo- 
caine and in both cases the necropsy 
revealed a tumor in the adrenal 
medulla. Proskauer (Therap. der 
Gegenwart, Dec., 1913). 

Hypoadrenic subjects tolerate sal- 
varsan badly. When this potent 
agent is to be used the signs of hypo- 
adrenia should be looked for. If 
these are present the patient should 
be confined to bed for a couple of 
days after the injection of salvarsan, 
and adrenalin be administered sys¬ 
tematically during that time. Ser- 
gent (Bulletin de la Soc. des Hop., 
Feb. 26, 1914). 

Toxic doses of all arsenicals of 
which we have any knowledge pro- 
duc“ definite pathological changes in 
the adrenals of guinea-pigs. These 
changes include congestion, hemor¬ 
rhage, disturbances in the lipoid con¬ 
tent, cellular degeneration and necro¬ 
ses, and reduction in the chromaffin 
content. The character and severity 
of the injury produced by different 
arsenicals vary with the chemical con¬ 
stitution of the compounds. From 
these facts they conclude that ad¬ 
renal injury is an important factor in 
arsenical intoxication. W. H. Brown 
and Louise Pearce (Jour, of Exper. 
Med., Nov. 1, 1915). 

The writer in a comprehensive 
clinical description of hemorrhage of 
the adrenals in the young as observed 
by him, states that the attack begins 
with extreme severity, high fever, 
vomiting, severe abdominal pain, 
cyanosis and often purpura, the pa¬ 
tients dying in from 6 to 24 hours 
after the onset of the symptoms. 
Friedrichsen (Jahrbuch f. Kinderh., 
vol. Ixxxvii, p. 109, 1918). 

ETIOLOGY. —That we are deal¬ 
ing with a relatively common morbid 
process is shown by the fact that Mattei, 
Rolleston and Le Conte, in 230 autop¬ 


sies in the newborn, found adrenal hem¬ 
orrhage in over 100 instances, or 45 per 
cent., while the proportion in adults is 
about 1 per cent. To explain the marked 
predilection of infants to this disorder 
many theories have been advanced: 
Weakness of the intra-adrenal vessels, 
either congenital or due to general dis¬ 
orders, such as syphilis, scorbutus, or, 
again, to lesions of the vascular walls, 
such as fatty degeneration, aneurism, 
etc.; lack of firmness of the medullary 
portion of the organ, the usual seat of 
the hemorrhage; compression by the 
uterus during labor of the inferior vena 
cava, thus offering resistance to the 
blood-streams from the adrenals which 
enter this great venous channel; ligation 
or prolapse of the funis, and other me¬ 
chanical factors capable of causing pass¬ 
ive congestion of all organs, including 
the friable and extremely vascular ad¬ 
renals. 

While all these agencies probably 
cause hemorrhage in a certain propor¬ 
tion of cases, the majority are due, as 
stated above, to some form of intoxica¬ 
tion, either toxins or endotoxins of in¬ 
fectious origin, or autogenous poisons, 
such as toxic waste products or auto¬ 
toxins of intestinal origin. Some ob¬ 
servers have ascribed the morbid pro¬ 
cess to a single hypothetical organism, 
but it has been clearly shown that dif¬ 
ferent germs could produce it, including 
the Staphylococcus aureus and albus 
(Riesman), the pneumococcus (Flamill 
and Dudgeon), the pneumobacillus of 
Friedlander (Litzenberg and White), 
and others. 

in adults hemorrhage occurs also, as 
a rule, as a complication of various dis¬ 
eases, some of which, such as septicemia, 
erysipelas and tuberculosis, are clearly 
of bacterial origin. Epilepsy, on the 
other hand, illustrates the class of cases 


ADRENALS, DISEASES OF (SAJOUS). 


425 


in which adrenal hemorrhage may be 
caused by autogenous poisons. In the 
adult, as shown under the next heading, 
several of these morbid processes may 
give rise to hemorrhagic cysts, which 
may eventually rupture into the abdom¬ 
inal cavity. 

[That a general toxemia is an active factor 
in adrenal hemorrhage has been demon¬ 
strated experimentally. Roger (Le bull, 
med., Jan. 21, 1894) found that inoculation 
of the guinea-pig by a pure culture of the 
pneumobacillus of Friedliinder is followed 
by abundant hemorrhage of the suprarenal 
capsules, the blood bursting through the 
great capsular vein and causing necrosis of 
the elements by mechanical compression. 
These hemorrhages do not occur in the rab¬ 
bit. Langlois (Le bull, med., Feb. 7, 1894) 
saw hemorrhages produced by’ the pyo- 
cyaneus bacillus. Pilliet (Le bull, med., Feb. 
7, 1894) has also observed such hemorrhage 
after intoxication by essence and nitrate of 
uranium. C. E. de M. S.] 

The adrenals are exceedingly vas¬ 
cular, and at times are subject to 
emporary passive engorgement. An¬ 
other cause of hemorrhage is unques¬ 
tionably bacterial invasion, and sev¬ 
eral hemorrhages of considerable size 
have been reported as due to this 
cause. The hemorrhage may be also 
due to toxemia from irritating chem¬ 
ical poisons. In animals who have 
been injected for experimental pur¬ 
poses, with sera or antitoxins, as, for 
example, that of diphtheria, severe 
congestions and, occasionally, hemor¬ 
rhages have occurred. A. J. M’Cosh 
(Annals of Surg., June, 1907). 

Instance in an epileptic who died 
during an attack of enteritis, and in 
whom the autopsy revealed recent 
extensive hemorrhage in both ad¬ 
renals. This seems to be a rare cause 
of death in adults, though not so 
uncommon in children. The reported 
case is one of Arnaud’s asthenic type, 
probably due to circulatory failure 
from sudden removal of the tonus, 
producing secretion of the supra- 
renals. J. F. Munson (Jour. Amer. 
Med. Assoc., July 6, 1907). 


Case of adrenal hemorrhage and 
acute edema of the lungs in the course 
of convalescence from acute nephritis 
due to erysipelas. The patient, a 
woman of 35 years, died suddenly on 
the fourth day of the nephritis, which 
had been brought on by exposure to 
cold. The autopsy showed, besides 
the evidences of pulmonary edema 
and intense acute nephritis, great 
distention of the adrenals by hemor¬ 
rhage into them, with complete de¬ 
struction of the medullary substance. 
Loederich (Le bull, med., July 8, 
1908). 

From an extensive experience in 
autopsy work in the newly born, the 
writer believes that hemorrhage into 
the suprarenals is very common, and 
that the evidence is sometimes micro¬ 
scopic instead of macroscopic. He 
has found some degree of hemor¬ 
rhage in infections due to the strep¬ 
tococcus, staphylococcus, pneumococ¬ 
cus. Bacillus pyocyaneus, the colon 
bacillus and a micrococcus he was 
unable to classify. We may have in¬ 
fections with the pneumococcus with¬ 
out any evidence of pneumonia. S. 
M. Hamill (Jour. Amer. Med. Assoc., 
Dec. 5, 1908). 

Hyperplasia of th'e adrenal is an al¬ 
most constant lesion in arteriosclerosis 
associated with chronic interstitial ne¬ 
phritis and left-sided hypertrophy, 
and it occurs with almost equal fre¬ 
quency in arteriosclerosis with chronic 
nephritis of the parenchymatous type; 
it is also a frequent lesion of arterio¬ 
sclerosis without nephritis and of ne¬ 
phritis without arteriosclerosis. Adre¬ 
nal hyperplasia is, consequently, prob¬ 
ably the result of some factor active in 
a period of life in which these affections 
are most frequent. The adrenal lesion 
con,sists of increase of connective tis¬ 
sue, round-cell infiltration, increase in 
the thickness of the vascular wall and 
hyperplasia of the adrenal cells proper. 
Pearce (Jour, of Exper. Med., Nov., 
1908). 

PATHOLOGY. — An important 
function of the adrenals is to destroy 
products of metabolism. This was first 


426 


ADRENALS, DISEASES OF (SAJOUS). 


shown by Abelous and Langlois, whose 
views have been confirmed by many ob¬ 
servers. Subsequently this function was 
found to apply to bacterial toxins. The 
prevailing view as to the pathogenesis 
of adrenal apoplexy is that, as a result 
of the active congestion of the adrenals 
incident upon infection and excessive 
functional activity and the high blood- 
pressure resulting therefrom, or passive 
congestion due to factors which prevent 
the free passage of blood out of the or¬ 
gans, such as pressure upon the adrenal 
veins, the inferior vena cava, etc., the 
capillaries become engorged and yield, 
thus causing a more or less diffuse inter¬ 
stitial hemorrhage. In some instances 
the entire adrenal parenchyma is de¬ 
stroyed, and the organ is more or less 
dilated by the blood accumulated in it, 
and may thus form a brownish or red¬ 
dish-blue mass, varying in size from that 
of a small walnut to that of the under¬ 
lying kidney. In other cases the organ 
ruptures, the blood flowing into the peri¬ 
toneum or the abdominal cavity. Both 
adrenals are involved in the morbid pro¬ 
cess in most instances. . Other organs, 
the lungs, the pleura, and skin in par¬ 
ticular, may also be the seat of hemor¬ 
rhage, the purpura witnessed in a large 
proportion of cases being naught else 
than a punctiform hemorrhage into the 
cutaneous tissues, due to excessive vas¬ 
cular tension. Death may be due to 
these hemorrhages or to the annihilation 
of the functions of the adrenals. 


Small ecchymoses into the adrenals 
occur frequently in the various infec¬ 
tious diseases and are to be considered 
toxic in origin. Hemorrhagic infarc¬ 
tion of both adrenals often leads to 
peritonitis and collapse and may result 
in death. It may, however, occur with¬ 
out any of these sequences. Large hem- 
atomata may be found in the adrenals. 
Hemorrhage into these glands may also 


occur under the following circum¬ 
stances: traumatic influences (under 
this class is found the form seen in 
the newborn) ; hemorrhagic diathesis; 
thrombosis of the suprarenal veins, 
which is the most common cause; and 
bacterial capillary embolism, which oc¬ 
cupies the second rank. The thrombi 
can affect the trunk or the tributaries 
of the suprarenal veins; they can occur 
in both or only in the right organ; they 
are to be regarded as marantic thrombi, 
occurring, as a rule, only in individuals 
suffering from some form of chronic 
disease. The peculiar anatomical dis¬ 
position of the vessels favors their 
formation. A primary suprarenal dis¬ 
ease does not precede these cases. 
Under the cases of bacterial capillary 
emboli are included those in which 
neither clinically nor anatomically can 
septic disease be observed. Bleeding 
into the adrenals may lead to atrophy 
of the organ. M. Simmonds (Vir¬ 
chow’s Archiv, Nov. 3, 1902; Med. 
News, Dec. 27, 1902). 

Acute hyperadrenia and adrenal hem¬ 
orrhage in the infant may also be due 
to toxemia. While the fetus is in utero 
its waste products are transferred to the 
maternal blood and converted therein 
into eliminable products. When its birth 
occurs it is left to its own resources, and 
if it is unable fully to break down its 
waste products these accumulate in its 
blood. Its waste products—and this ap¬ 
plies as well to certain toxins, including 
those enumerated above—excite power¬ 
fully both the adrenal system and the 
vasomotor center (hence the flushing 
following a copious meal). If the adre¬ 
nal system can thus be made to prevail, 
the wastes (or toxins) will be gradually 
destroyed, and the vasomotor center will 
not be abnormally excited. If it is not, 
the wastes accumulate, and the vaso¬ 
motor center being powerfully stimu¬ 
lated, the vascular tension and the blood- 
pressure become intense; this being fur¬ 
ther enhanced by the excess of adrenal 


ADRENALS, DISEASES OF (SAJOUS). 


427 


secretion produced, the pressure be¬ 
comes such that the adrenal tissues, al¬ 
ready overburdened with blood as a 
feature of their overactivity, yield — 
along with many cutaneous capillaries, 
as witnessed by the hemorrhagic pur¬ 
pura. 

Examination of the adrenals in 16 
cases of diphtheria, 10 of variola, 23 
of lobar- and broncho- pneumonia, 5 
of typhoid fever, 1 of tetanus and 4 
of streptococcus infection. The 
glandular cells were profoundly al¬ 
tered. There was also hemorrhagic 
extravasation into the stroma, in 
which the polynuclear neutrophilic 
leucocytes are especially abundant. 
True abscess formation occurs chiefly 
in the prolonged infections of variola 
and typhoid fever. No peculiar alter¬ 
ations were observed as the result of 
special infections and the changes in 
general were common to all the 
cases examined. A pericapsular scle¬ 
rosis, cortical and central, was pres¬ 
ent in most cases. This chronic 
lesion is not due to the acute process, 
but is to be regarded as the result of 
previous repeated or continued infec¬ 
tions. The writers regard the ad¬ 
renals as possessing an important 
function in the resistance of the 
organism to infection. Oppenheim 
and Loeper (Archives de med. exper., 
Sept., 1901). 

Case of a male infant, four days 
old, who was born after a normal 
labor. On the fourth day after birth 
the infant ceased to pass urine and 
after total suppression for twenty- 
four hours it died. At the autopsy 
the chief interest centered in the 
suprarenal bodies; the left one was 
replaced by a tumor the size of a 
hen’s egg and the right one pre¬ 
sented a tumor as large as a cherry 
at its apex. The structure of both 
tumors was identical, both showing a 
hypoplasia of the fascicular zone fol¬ 
lowed by marked fatty changes and 
necrosis. In the case of the growth 
in the left suprarenal body, liquefac¬ 
tion of the necrosed central portions 
gave rise to a cyst which was filled 


with cell debris. Both growths were 
considered to belong to the group of 
adenoma. A. S. Warthin (Archives 
of Pediatrics, Nov., 1901). 

Results obtained by inoculating 
rabbits and, guinea-pigs with cultures 
of various micro-organisms. The 
micro-organisms used were diplo- 
cocci, typhoid bacilli, bacterium coli, 
Staf^Iiylococcus aureus, streptococci, 
anthrax bacilli, and diphtheritic bac¬ 
illi. In the experiments with active 
cultures there was always great hy¬ 
peremia of the suprarenal bodies and 
in the more active cases there were 
hemorrhages. E. Frederic! (Lo 
Sperimentale, Iviii, Fasc. 3, 1904). 

Common pathological cnanges found 
in the suprarenals are hemorrhage, 
which converts the medulla of the 
organ into a pulpy mass, and em¬ 
bolism of the suprarenal artery, 
whereby the entire organ is des¬ 
troyed. Occasionally, one or both 
organs will be converted into the 
large bluish tumors, whose contents 
are fluid blood. This is especially 
common in the newly born, and 
many believe that the motions neces¬ 
sary for artificial respiration are the 
real cause. In a number of cases ob¬ 
served by the author, however, arti¬ 
ficial respiration was not resorted to, 
and it is likely that severe labor, par¬ 
ticularly if the child is in the breech 
position, will furnish the necessary 
trauma to rupture the friable supra¬ 
renal tissue and thus giye rise to a 
hematoma. If both organs are af¬ 
fected the symptoms are those of 
Addison’s disease, and death rapidly 
sets in. S. Oberndorfer (Wiener 
klin. therap. Woch., June 18, 1905). 

Conclusions based on a study of 
119 cases including 2 personal cases: 

1. Hemorrhage of the suprarenal cap¬ 
sules is more common than hemor¬ 
rhage in the other viscera. 2. This is 
due primarily to the close relation of 
the adrenals to the vena cava, mak¬ 
ing congestion easy, and to the 
peculiar anatomical construction which 
favors hemorrhage. 3. A weakness of 
the vessel walls, either normal deli¬ 
cacy or pathological alteration favors 


428 


ADRENALS, DISEASES OF (SAJOUS). 


the rupture. 4. The place of election 
of the hemorrhage is usually in the 
internal cortical zone because of its 
vascularity and the anatomical ar¬ 
rangement of the vessel. 5. The 
bleeding always follows active or 
passive congestion. 6. Passive con¬ 
gestion may be caused by difficult 
labors, obstetric operations, throm¬ 
bosis, or, in short, anything that 
would favor venous stasis. 7. Active 
congestion is induced by infection or 
any toxemia which incites hyperemia 
by a superactivity of the gland. 8. 
The findings of the pneumobacillus 
of Friedlander in the 2 cases per¬ 
sonally reported and other bacteria 
in 5 additional cases prove beyond 
question that infection is a cause of 
adrenal hemorrhage. 9. Death re¬ 
sults either from loss of blood or an 
interference with the physiological 
function of the gland. J. C. Litzen- 
berg and S. Marx White (Jour. 
Amer. Med. Assoc., Dec. 5, 1908). 

TREATMENT. —The literature of 
the subject is suggestively silent on the 
prevention and treatment.of this condi¬ 
tion. The foregoing conception of its 
pathogenesis, however, opens a greater 
field in this connection. 

As to prophylaxis, it must be borne in 
mind that acute hyperadrenia is present 
when the blood-pressure and the febrile 
process are abnormally high. Antipy¬ 
retics are worse than useless, since they 
further increase the blood-pressure and 
through this fact the danger of adrenal 
congestion, which may lead to hemor¬ 
rhages. The physiological saline solu¬ 
tion offers, on the other hand, all desir¬ 
able qualities. It does not, as argued 
theoretically by some authors, increase 
the vascular tension, even if injected 
intravenously, as shown by the experi¬ 
ments of Sollmann (Archiv f. exper. 
Path. u. Pharm., Bd. xlvi, S. i, 1901), 
Briggs (Johns Hopkins Hosp. Bull., 
Feb., 1903), and others, any excess of 
fluid leaves the vessels at once. By re¬ 


ducing the viscidity of the blood, saline 
solution tends to relax the blood-ves¬ 
sels; by increasing its osmotic proper¬ 
ties it facilitates greatly the penetration 
of the plasma into the lymphatic chan¬ 
nels, thus further reducing the vascular 
tension. The bactericidal and antitoxic 
properties of the blood are not reduced 
in the least by this procedure; there is 
considerable evidence available to show, 
in fact, that they are enhanced (see “In¬ 
ternal Secretions,” 4th ed., vol. ii, p. 
1367, 1911). Saline solution, therefore, 
should be used intravenously in emerg¬ 
ency cases; subcutaneously in threaten¬ 
ing cases, and per rectum in all cases in 
which there is any likelihood whatever 
that adrenal hemorrhage might occur. 
If employed from the onset of all infec¬ 
tions, as I suggested in 1903, the blood- 
pressure would probably never be raised 
sufficiently to endanger the adrenals. 

As to drugs, we have several at our 
disposal which lower the blood-pressure. 
In emergency cases nitrite of amyl by 
inhalation, with nitroglycerin (or, in 
children, the sweet spirit of niter) to 
sustain the effect, appears indicated. 
Chloral hydrate has been used advan¬ 
tageously by J. C. Wilson in certain ex¬ 
anthemata, to subdue the cutaneous dis¬ 
comfort and as a sedative; as it is also a 
vasomotor depressor, it might also serve 
advantageously in all but infants in 
whom the respiratory mechanism is de¬ 
fective. Veratrum viride suggests it¬ 
self as another useful agent of this class. 
Of all measures, however, the saline so¬ 
lution is much to be preferred. 

When the hemorrhage has occurred 
the lethal phenomena are of such short 
duration in most cases as to have sug¬ 
gested, we have seen, the term “adrenal 
apoplexy.” In a fair proportion of 
cases, however, the hemorrhage causes 
sudden hypoadrenia. The treatment of 


ADRENALS, DISEASES OF (SAJOUS). 


429 


this condition is that indicated in the 
emergency cases of terminal hypoadre- 
nia (see page 413). If the hemorrhage 
has not been too extensive the chances 
of recovery will be greatly increased by 
the use of adrenal or pituitary prep¬ 
arations, the latter owing its proper¬ 
ties, in my opinion, to the adrenal 
chromaffin substance the pituitary con¬ 
tains. These agents will help to sustain 
oxidation and metabolism while the 
adrenal lesion is undergoing resolution. 

Although the adrenals have been 
regarded as impervious to X-rays, 
the writers found that hyperplasia 
with accompanying overactivity of 
the glands is reduced by them, owing 
to a retarding influence upon tissue 
proliferation. They obtained a reduc¬ 
tion of blood-pressure, as shown by 
Pachon’s sphygmo-oscillometer, fol¬ 
lowing irradiation of the adrenals. 
Out of 16 cases, the pressure re¬ 
mained high in only 1. Zimmern and 
Cottenot (Arch. d‘elect. med., June 7, 
1912). 

The writer analyzes the recent 
literature on hemorrhage in the 
suprarenals in children. When it is 
actual apoplexy, it is inevitably 
fatal, but with anything short of this, 
with low blood-pressure, intermittent 
cyanosis and asthenia, large and re¬ 
peated doses of adrenalin are called 
for, watching over the effect by the 
arterial pressure. He recalls the in¬ 
teresting case of Vollbach’s in which 
a girl of 15 presented purpura a year 
before developing Addison’s disease. 
Comby (Arch, de Med. des Enfants, 
Dec., 1918). 

HEMORRHAGIC PSEUDO¬ 
CYSTS OF THE ADRENALS.— 
In most instances hemorrhagic blood- 
cysts are the results of acute hyperad- 
renia in the course of some infection or 
intoxication in which the adrenal hem¬ 
orrhage has been limited to a small 
area, which eventually develops into a 
cyst. 


SYMPTOMS.—These growths may 
give rise to no symptoms, other, per¬ 
haps, than a sensation of weight, until 
quite large, when pain supervenes. This 
is at first indefinite, though most 
marked in the region of the tumor, in 
the right or left loin, or in the upper 
portion of the abdomen and loin. The 
neuralgia-like pain becomes increas¬ 
ingly severe, and radiates in various 
directions, especially toward the hip 
and thigh of the corresponding side, 
and is subject to exacerbations, which 
may be very severe, especially after 
meals. Epigastric pain and vomiting— 
which affords relief—occur in some 
cases, especially during these exacer¬ 
bations of suffering. 

While such a cyst or adrenal hema¬ 
toma may attain a large size, the fact 
that the opposite adrenal remains 
uninvolved practically excludes the 
production of symptoms of altered 
adrenal function, the signs of the 
tumor being merely a sensation of 
weight and pain due to pressure 
on surrounding sensitive structures. 
Subsequently, the patient may sud¬ 
denly begin to fail, losing weight and 
developing dyspnea, polyuria, hema¬ 
turia, and even slight bronzing. The 
termination is usually through rup¬ 
ture into the abdominal cavity. 
Sajous (Da Costa’s Therapeutics, 
1918). 

The tumor may manifest itself at first 
merely by enlargement of the abdomen. 
The bulging then becomes more clearly 
defined on one side or the other (this 
variety of growth being almost invari¬ 
ably unilateral), under the lower ribs, 
which may be pushed outward if the 
growth is sufficiently large, or below 
their free border, i.e., between them and 
the superior spine of the ilium. If the 
tumor, which grows downward and for¬ 
ward, is sufficiently below the ribs to be 
palpated, it is usually found globular, or 


430 


ADRENALS, DISEASES OF (SAJOUS). 


oval, smooth and tense, though elastic, 
to the touch. Fluctuation may also be 
elicited. In some cases it is immovable 
under palpation, though it may, at first, 
follow the respiratory movements. Nor 
can it be grasped as is sometimes possi¬ 
ble in renal tumors; if small, the tumor 
is movable, either upward or downward, 
but this mobility gradually decreases as 
the tumor develops. The growth is 
sometimes sensitive under pressure. 

At first, several years, perhaps, the 
patient may appear normal in every 
other respect, be well nourished, ruddy, 
etc. With comparative suddenness, how¬ 
ever, he begins to fail, losing flesh rap¬ 
idly, all the other symptoms mentioned, 
to which dyspnea and a sense of con¬ 
striction about the chest is added, be¬ 
coming more severe. If the cyst does 
not rupture, polyuria, hematuria, and 
even slight bronzing may appear. It is 
probable, however, that this train of 
phenomena is witnessed only in a very 
small proportion of cases, rupture and 
hemorrhage constituting the “adrenal 
hemorrhage” in adults treated under the 
preceding heading, being the outcome in 
practically every instance. 

Adrenal hemorrhage in the newborn 
is probably not uncommon, but in the 
great majority of cases there are no 
symptoms to indicate the occurrence of 
such a lesion, and the hematoma is 
quickly absorbed. It is equally difficult 
to understand why in adults these 
hemorrhages should occur. The deep 
situation of the adrenal bodies would 
seem to be sufficient protection from in¬ 
jury, except that of the severest char¬ 
acter, and yet in a certain proportion 
of these cases the cause has aparently 
been a trauma. A. J. M’Cosh (Annals 
of Surg., June, 1907). 

[This abstract indicates the drift of the 
prevailing conception of the pathogenesis of 
these growths. While local lesions are as¬ 
cribed to the concomitant disorder, the ad¬ 
renals, being supposedly affected directly by 


the toxin or poison that may be present, are 
thought to explain some cases, others require, 
it is believed, some form of traumatism. 
It is to the excessive blood-pressure pro¬ 
duced by the toxin that the vascular rup¬ 
tures to which the hemorrhage is due should 
be ascribed. C. E. de M. S.] 

DIAGNOSIS.—The symptomatol¬ 
ogy of adrenal cyst, apart from the loca¬ 
tion of the tumor, does not present, as 
just shown, very characteristic features. 
The location of the pain sometimes sug¬ 
gests intercostal neuralgia; but inas¬ 
much as pain occurs only when the 
growth is large, percussion and palpa¬ 
tion will reveal the presence of a tumor. 
In neuralgia the pain is also apt to be 
localized, thus distinguishing it from the 
radiating pain of adrenal cyst. The sud¬ 
den onset of severe pain may be taken 
for acute pancreatitis. The location of 
pain and tenderness in the upper left ab¬ 
dominal quadrant, the subnormal tem¬ 
perature and the early lethal trend— 
death occurring sometimes within three 
days—clearly point to the latter dis¬ 
ease. Pancreatic cyst is also differen¬ 
tiated by its location and its association 
with glycosuria, stearrhea, and imper¬ 
fect digestion of fats and albuminoids. 
Hydatid cyst of the liver, another source 
of confusion, is attended by the presence 
of biliary pigments in the urine, the ap¬ 
pearance of cysts in the stools and vom¬ 
ited matter, and with obstruction phe¬ 
nomena. Cancer of the spleen may be 
recognized by the more nodular outline 
of the growth and the cachectic phe¬ 
nomena. 

Hydatid cyst of the spleen is 
usually associated with hydatid cysts 
elsewhere, and may be accompanied by 
the presence of booklets in the excre¬ 
tions. Puncture of the growth should 
be carefully avoided when there is any 
suspicion whatever that an adrenal 
blood-cyst is present. Renal cysts are 


ADRENALS, DISEASES OF (SAJOUS). 


431 


more easily palpated bimanually, and 
are usually freely movable. 

Cysts are due to the tendency of 
the adrenals to hemorrhage. Four¬ 
teen cases are reported in literature, 
of which 7 were post-mortem reports 
or complications of other adrenal 
tumors. The other cases were well- 
defined blood-cysts of the adrenal 
glands. The author reports the case 
of a waitress with a history of right 
side pain of a cramping nature, on 
several occasions—she thought 5 or 6. 
A large tumor was present in the 
upper right abdomen; shock, pain, 
difficult breathing, rapid pulse. 

Operation showed a cyst covered 
with peritoneum attached to the back 
above the right kidney. All organs 
were displaced by the cyst, which was 
as large as an adult head. The pa¬ 
tient recovered, and was well 1 year 
later. H. E. Pearce (Trans. West. 
Surg. Assoc.; Surg., Gynec. and Ob- 
stet., Feb., 1917). 

ETIOLOGY.—Adrenal blood-cyst 
has been ascribed to many morbid con¬ 
ditions. Acute intoxications, especially 
diphtheria, typhoid fever, burns, osteo¬ 
myelitis, hepatic abscess and tuberculo¬ 
sis, have been regarded as initial factors 
of these growths, a small cyst formed 
during the active stages of these dis¬ 
eases, or, as a complication thereof, 
gradually increasing in size until the 
foregoing phenomena or adrenal hem¬ 
orrhage occur. In the light of the data 
submitted in the foregoing pages, they 
are merely after-eflfects or complica¬ 
tions, in other words, of the damage 
done to the adrenals during an acute 
febrile toxemia. 

Atheroma of the adrenal arteries is 
also regarded, and doubtless justly, as a 
source of initial lesions, but it is prob¬ 
able that cerebral lesions of the same 
kind and apoplexy, which have been 
considered by some authors as etiolog¬ 
ical factors, are merely concomitant 
lesions due to general arteriosclerosis. 


Thrombosis of the adrenal vein by 
blocking the efferent circulation has also 
been incriminated, while traumatism is 
known to have started the morbid proc¬ 
ess in at least two instances. 

PATHOLOGY.—While older in¬ 
vestigators, including Klebs, Virchow 
and Heuschen, considered these growths 
as retention cysts, similar to those 
formed in the thyroid, and thus termed 
them “struma adrenalis,’’ the prevail¬ 
ing view at the present time is that a 
small hematoma or an acute congestive 
process—though erroneously, in my 
opinion, ascribed to local intoxication— 
initiates the growth. As the latter in¬ 
creases in size the adrenal structure is 
gradually destroyed and the content is 
no longer—unless a recent hemorrhage 
has occurred—merely blood, but a more 
or less fluid magma of detritus, broken- 
down blood- and tissue- cells, flakes 
or fibrin, cholesterin crystals, etc., 
which may be dirty yellow, greenish or 
brownish in color. Microscopically, the 
walls of the cyst, which vary from 
to Ys inch in thickness, are composed of 
fibrin tissue; the inner aspect shows 
shreds or remnants of the adrenal 
cortex. 

Certain thickened portions of the 
capsule and what semiorganized clots 
the cyst may contain may be found to 
include small cysts, chalky deposits. 
These growths sometimes become very 
large—as large as an adult head in a 
case of Chiari’s—and contain several 
pints of blood or liquefied blood and tis¬ 
sue elements. 

PROGNOSIS.—The fact that this 
growth is practically always unilateral, 
and that the loss of one adrenal does 
not compromise life, as does removal of 
both organs, make it possible to remove 
the growth with safety. The frequent 
instances of severe collapse and shock 


432 


ADRENALS, DISEASES OF (SAJOUS). 


that have followed these operations sug¬ 
gest that the operative prognosis can¬ 
not but be improved by resorting to 
those surgical procedures which will en¬ 
tail the least possible handling of the 
intraperitoneal organs and of the sym¬ 
pathetic ganglia, all of which are well 
known to produce shock readily by re¬ 
flex action. 

TREATMENT.—The treatment is, 
of course, entirely surgical. The cyst 
may be removed through either an ab¬ 
dominal or lumbar incision. In accord 
with M’Cosh’s advice, which a review 
of the operative results recorded fully 
sustains, preference should be given to 
the lumbar incision. The approach is 
more direct; it avoids the handling of 
the intraperitoneal organs, which must 
necessarily take place if the tumor be 
reached through the abdominal incision, 
and it affords the most direct route for 
drainage. In the average case, an ob¬ 
lique incision from behind downward 
and forward below the last rib, which 
has been found most convenient for ex¬ 
tirpation of the kidney and ureter, is as 
applicable here. If much space is 
needed, it is safer to remove the last rib 
than, as some European surgeons have 
advised, to resort to the abdominal in¬ 
cision, which, as previously stated, en¬ 
tails considerable shock. The tumor is 
sometimes found so firmly adherent to 
the kidney that removal of this organ 
becomes necessary. 

In the case of large serous cysts 
complete extirpation should be prac¬ 
tised if possible; but if the sac can¬ 
not be readily and gently detached 
from the surrounding parts, the sur¬ 
geon should rest content with partial 
resection of the wall of the cyst, and 
resection of the wall of the cyst. 
Terrier and Lecene (Revue de Chir., 
vol. xxvi. No. 9, 1906). 

A blood-cyst filling the entire upper 
abdomen was successfully removed 


by the writer from a woman of 43. 
This enormous tumor was back of 
the peritoneum, and its removal was 
facilitated by tapping, releasing a 
quart of brownish fluid. The pa¬ 
tient convalesced rapidly, although 
the operation had been long and 
tedious on account of adhesion of the 
cystic adrenal to adjacent organs. He 
found 11 cases in the literature with 
5 recoveries. Kiittner (Beitr. z. klin. 
Chir., Dec., 1912). 

FUNCTIONAL HYPOADRE- 
NIA. 

DEFINITION.—Functional hypo- 
adrenia is the symptom complex of de¬ 
ficient activity of the adrenals, due to 
inadequate development, exhaustion by 
fatigue, senile degeneration, or any 
other factor which, without provoking 
organic lesions in the organs or their 
nerve-paths, is capable of reducing their 
secretory activity. Asthenia, sensitive¬ 
ness to cold, and cold extremities, hy¬ 
potension, weak cardiac action and 
pulse, anorexia, anemia, slow metabo¬ 
lism, constipation, and psychasthenia are 
the main symptoms of this condition. 

In a number of examples of supra¬ 
renal insufficiency in troops incident 
upon fatigue, the writers by supply¬ 
ing the lacking adrenal principle, 
cured the disturbances when they 
took the form of a diarrhea resemb¬ 
ling cholera, as also in grave gastro¬ 
intestinal toxic infections. The men 
thus affected had led a sedentary life 
before the war. Satre and Gros 
(Prog, med., June 15, 1918). 

SYMPTOMATOLOGY AND 
PATHOGENESIS.—The process of 
development in the child and the influ¬ 
ence of senility on the adrenals make it 
necessary to discriminate between the 
main stages of life, infancy, childhood, 
adult and old age, in describing this 
condition. 

Infancy.—Although the adrenals 
are relatively large in the infant (one- 


ADRENALS, DISEASES OF (SAJOUS). 


433 


third the size of the kidney at birth), 
their functions are limited to the carry¬ 
ing on of the vital process, at least dur¬ 
ing the first year of life, the mother’s 
milk supplying the antitoxic products 
capable of protecting it against the de¬ 
structive action of poisons of endogen¬ 
ous and exogenous origin. This pro¬ 
tective influence of maternal milk is 
clearly defined in the following quota¬ 
tion from Professor William Welch’s 
Harvey Lecture: ‘Tt is an important 
function of the mother to transfer to 
the suckling, through her milk, immu¬ 
nizing bodies, and the infant’s stomach 
has the capacity, which is afterward lost, 
of absorbing these substances in active 
state. The relative richness of the suck¬ 
ling’s blood in protective antibodies, as 
contrasted with the artificially fed in¬ 
fant, explains the greater freedom of 
the former from infectious diseases.” 
-Striking proof of this is afforded by the 
fact that during the siege of Paris, in 
1870-71, according to J. E. Winters 
(“Practical Infant Feeding,” p. 6), 
“while the general mortality was dou¬ 
bled, that of infants was lowered 40 per 
cent, owing to mothers being driven to 
suckle their infants.” 

Childhood.—The predilection of 
children to certain infectious diseases 
obviously indicates that it is not only in 
infancy that vulnerability to these dis¬ 
orders exists; it exposes life during the 
first decade, and more, of the child’s ex¬ 
istence. If, then, in the infant the ma¬ 
ternal milk, as Welch says, protects the 
suckling against such diseases, at least 
to a considerable extent, we must con¬ 
clude that the same underlying cause of 
vulnerability persists several years, i.e., 
until it has in some way been overcome. 
The adrenals acquire, with other or¬ 
gans, the power to supplant the mother 
in contributing antitoxic bodies to the 

1 - 


blood; they supply internal secretions 
which fulfill this role. 

These facts point to the adrenals as 
at least prominent organs among those 
whose inadequate development explain 
the special vulnerability of children to 
certain infections, the “children’s dis¬ 
eases.” It becomes a question now 
whether there are degrees of this hypo- 
adrenia which render the child more or 
less liable to infection. 

That degrees of hypoadrenia exist in 
children is, in reality, a familiar fact to 
every physician when the signs of this 
condition are placed before him. The 
ruddy, warm, hard-muscled, heavy, out- 
of-door, romping child with keen appe¬ 
tite and normal functions, is one in 
whom the adrenals are as active as the 
development commensurate with its age 
will permit. He is ruddy and warm be¬ 
cause oxidation and metabolism are per¬ 
fect and the blood-pressure sufficiently 
high to keep the peripheral tissues well 
filled with blood; his muscles, skeletal, 
cardiac and vascular, are strong because, 
in addition to being well nourished, they 
are exercised and well supplied with the 
adrenal secretion, which, as shown by 
Oliver and Schafer, sustains muscular 
tone. As normal outcome of this state, 
we have constant stimulation of the 
functional activity of the adrenals. The 
muscular exercise and maximum food- 
intake involve a demand for increased 
metabolism and oxidation, and the re¬ 
sulting greater output of wastes imposes 
upon the adrenals, as participants in the 
oxidation and autoprotective processes, 
greater work, more active growth and 
development, with increase of defensive 
efficiency as normal result. 

The pale, emaciated, or pasty child, 
with cold hands and feet, flabby mus¬ 
cles, whose appetite is capricious or de¬ 
ficient—the pampered house-plant so 
-28 


434 


ADRENALS, DISEASES OF (SAJOUS). 


often met among the rich—represents 
the converse of the healthful child de¬ 
scribed, just as does the ill-fed, perhaps 
overworked, child of the slums. The 
emaciation, the cold extremities, indi¬ 
cate deficient oxidation, metabolism and 
nutrition owing to the torpor of the ad-' 
renal functions; the pallor is mainly due 
to a deficiency of the adrenal principle 
in the blood and to the resulting low 
blood-pressure, which entails retroces¬ 
sion of the blood from the surface. 
This child is not ill, but the hypoadrenia 
which prevails normally, owing to the 
undeveloped state of its adrenals, is ab¬ 
normally low, and it is vulnerable to 
infection. 

That all conditions which in the adult 
tend to produce functional hypoadrenia 
affect the child at least to the same ex¬ 
tent, is self-evident. 

Adult Age.—As in the child, the ad¬ 
renals may be inherently weak. Such 
subjects do not, as in hypothyroidia, 
show signs of myxedema; but their cir¬ 
culation and heart action are feeble, they 
tend to adiposis, and show other signs 
of hypoadrenia. I have witnessed sug¬ 
gestive bronze spots in such cases. As 
a rule, however, the development of the 
adrenals in adults is an accomplished 
fact—as also that of their coworkers in 
the immunizing process, the thyroid and 
pituitary, we shall see. The adrenals, 
fully capable of sustaining oxidation 
and metabolism, are able to defend the 
organism adequately; indeed, they do 
more: by sustaining oxidation and met¬ 
abolism up to its highest standard in all 
organs, they also preserve the efficiency 
of all other defensive resources, includ¬ 
ing phagocytosis, with which the body is 
endowed to their highest level. On the 
whole, the normal adult zvhose adrenals 
functionate normally is relatively resist¬ 
ant to infection. The infrequency with 


which we are infected, notwithstanding 
daily exposure in our professional work, 
attests to this fact. 

Functional hypoadrenia appears, how¬ 
ever, when, irrespective of any disease, 
and as a result of the vicissitudes of our 
existence, the adrenals are subjected to 
abnormal secretory activity. 

Fatigue is a prominent factor in this 
connection. Mosso’s ergograph shows 
clearly the functional efficiency of the 
forearm. If by means of this instru¬ 
ment we compare the muscular power 
of a case of Addison’s disease with that 
of any other kind of sufiferer, whose 
muscles are organically normal, a strik¬ 
ing difference will be noticed: signs of 
fatigue appear very soon, and muscular 
impotence asserts itself where an ad¬ 
vanced case of tuberculosis, for exam¬ 
ple, will be able to show appreciable 
strength. Intense asthenia is, in fact, a 
symptom of Addison’s disease almost 
as characteristic as the bronze spots. It 
is as pre-eminent after experimental re¬ 
moval of both adrenals. This harmo¬ 
nizes with Oliver and Schafer’s demon¬ 
stration of the influence of the adrenal 
secretion over muscular tone. Many 
other proofs could be adduced to show 
that there is a close relationship between 
fatigue and the functions of the ad¬ 
renals. The pale and drawn face of an 
exhausted man, the readiness with which 
he suffers from the effects of cold and 
exposure, especially in the intestines, are 
familiar features of daily life. 

The unusual prevalence of disease 
among soldiers in the field is, of course, 
partly due to the defective sanitation 
that a campaign entails; but fatigue— 
particularly that due to heavy march¬ 
ing, carrying heavy accoutrements—is, 
in my opinion, an important predispos¬ 
ing cause, through its influence upon the 
adrenals. Not only are these organs 


ADRENALS, DISEASES OF (SAJOUS). 


435 


called upon to sustain general oxidation 
and metabolism at a rate exceeding by 
far that which amply suffices for normal 
avocations, but the fact that, as shown by 
Abelous and Langlois {loc. cit.), they 
also serve to destroy the toxic products 
of muscular activity, constitute another 
cause of drain upon their secretory re¬ 
sources. “Fatigue,” write Morat and 
Doyon (Traite de Physiologie,” Art. 
“Secretions Internes,” p. 441, 1904), re¬ 
ferring to experimental fatigue in ani¬ 
mals deprived of their adrenals, “has an 
aggravating influence, as first indicated 
by Abelous and Langlois, and confirmed 
by Albanese and all authors. Hultgren 
and Andersson have even observed 
sudden death as a result of powerful 
movements of the body.” 

Debility from any source, starvation, 
loss of blood, etc., as efficiently renders 
the body vulnerable to disease: “Com¬ 
bine toxin and antitoxin, and inject the 
mixture,” writes Professor Charrin 
(“Les Defenses Naturelles de TOrgan- 
isme,” p. 63, Paris, 1898) ; “no harm 
will follow. But weaken the animal by 
starvation or slight bleeding and admin¬ 
ister the same injection; death will fol¬ 
low with all the signs of poisoning by 
the toxin, with congested adrenals.” 
, , , “That relations exist between 

the adrenals and infection,” urges the 
same authority, “is today an incontro¬ 
vertible fact.” It follows, therefore, 
that hypoadrenia from any source 
should render the body vulnerable to 
disease. Deficient food, excessive work, 
that of the sweat-shops for example, ac¬ 
count for much of the predilection of 
our slums as foci of disease, their filth 
nurturing the appropriate germs. 

Masturbation and excessive venery 
are important morbid factors in this 
connection. The pallor and asthenia 
witnessed in these cases, so far unex¬ 


plained, can readily be accounted for if, 
as I believe, the liquid portion of the 
semen is rich in adrenal principle. This 
is suggested by the fact that spermin, 
the purest of testicular preparations, 
gives the same tests and acts precisely 
as does the adrenal principle. The 
latter is an oxidizing body acting cata- 
lytically; it resists all temperatures up 
to and even boiling; it is insoluble in 
ether and practically insoluble in abso¬ 
lute alcohol, and gives the guaiac, Flor¬ 
ence, and other hemin tests. Now, sper¬ 
min not only raises the blood-pressure, 
slows the heart and produces all other 
physiological effects peculiar to the ad¬ 
renal principles, but its solubilities arc 
the same; it gives the same tests; it re¬ 
sists boiling. Moreover, it is regarded 
in Europe as a powerful “oxidizing 
tonic,” and has been found equally use¬ 
ful in disorders in which adrenal prepa¬ 
rations had given good results. The in¬ 
ference that spermin consists mainly of 
the adrenal product suggests that it 
should not be regarded as specific to the 
testes, but, instead, a constituent of the 
blood at large; not only did this prove 
to be the case, but it was found in the 
blood of females as well as in that of 
males. 

Old Age.—Perpetual life would doubt¬ 
less be ours were it not that all living 
organic matter is subjected, after more 
or less precarious periods of growth and 
adult existence, to one of decline and 
final disintegration. This applies par¬ 
ticularly to the adrenals, if their func¬ 
tions are, as I hold, to sustain oxidation 
and metabolism, the fundamental pro¬ 
cesses of the living state. Indeed, the 
senile state may be said to be as evident 
in these organs as it is in the features 
of the aged. 

Series of corrosion preparations, of 
the veins of the left adrenal in different 


436 


ADRENALS, DISEASES OF (SAJOUS). 


people, aged, respectively, 22, 30, 
80, and 82, using the same inject¬ 
ing substance and technique. They 
showed conclusively that the vascular 
system of the adrenals becomes 
steadily smaller as adult age wanes, 
being greatly shrunken in old people. 
Landau (St. Petersb. med. Woch., 
June 14, 1908). 

According to Landau (St. Petersb. 
med. Woch., June 14, 1908), Ecker, 
Llenie, and von Kdlliker found that fat 
occurred in increasing quantities in the 
adrenal cortex as age advanced, while 
Hultgren and Andersson found fibrous 
tissue between the cortex and medulla 
in very old animals. Minervini (Jour, 
d’anat. et de physiol., pp. 449 and 639, 
1904) found a similar condition in the 
medulla of aged individuals. Dostojew- 
ski, moreover, observed a marked—oc¬ 
casionally very great—reduction in the 
size of the adrenals in the aged. Rolles- 
ton (Lancet, Mar. 23, 1895) has also 
called attention to this fact. 

Landau studied the influence of 
age on the vessels, large and small, 
of the adrenals, adopting for the pur¬ 
pose a process introduced by Rauber 
and applied by many others, including 
Bezold, Hyrtl, and Lieberkuhn, to the 
study of other organs, viz., injection of 
the vessels with some hardening sub¬ 
stance, and the subsequent use of a cor¬ 
rosion method to destroy the paren¬ 
chyma. The adrenals receiving their 
blood through a number of small arte¬ 
ries, the adrenal vein, which contains no 
valves, was used for the injection. The 
annexed plate shows the result. The 
vessels, and therefore the adrenals, are 
well developed and in full bloom, as it 
were, in the adrenals of the three young 
adults, while those of the aged are 
shrunken and correspondingly deficient 
as blood-channels—a certain index of 
the lowered activity of the adrenal func¬ 


tions, and, through these, of the vital 
process they sustain. 

The asthenia of old age thus finds a 
normal explanation in the defective sup¬ 
ply of adrenal secretion—precisely as it 
does in Addison’s disease. In fact, Rol- 
leston states that atrophy of the glands 
in the young may produce this disease. 
Lorand (“Old Age Deferred,” Am. ed., 
p. Ill, 1910), in his recently published 
book on old age, urges, in fact, that “old 
age is caused by degeneration of the 
ductless glands, and that there exists a 
condition of autointoxication in old age” 
quite in keeping, I may add, with a de¬ 
cline of the antitoxic power shown by 
the adrenals. Lorand, who has ante¬ 
dated others in showing the influence 
of the ductless glands upon old age, has 
found his views confiremed by Camp¬ 
bell (Lancet, July, 1905), Pineles, Sir 
Herman Weber, and also—though he 
denies a relationship between old age 
and myxedema—Metcnnikoff. 

In his closing remarks on the causa¬ 
tion of old age, Lorand remarks: “It is 
evident from the above considerations 
that all hygienic errors, be they errors 
of diet or any kind of excess, will bring 
about their own punishment, and that 
premature old age, or a shortened life, 
will be the result. In fact, it is mainly 
our fault if we become senile at 60 or 
70, and die before 90 or 100.” Hence 
the motto of his title page:— 

“Man does not die. 

He kills himself.” 

— Seneca. 

In the light of the data I have sub¬ 
mitted, however, it is clear that the le¬ 
sions to which the adrenals are subjected 
during infections and autointoxication, 
from birth to the last day of life, do 
greatly shorten it by limiting the func¬ 
tional area of the organs through the 
local fibrosis they entail. It is quite 


ADRENALS, DISEASES OF (SAJOUS). 


437 


probable, in fact, that centenarians owe 
their prolonged longevity mainly to in¬ 
tegrity of their adrenals. 

Hygiene, and particularly those of its 
divisions which bear directly upon the 
prevention of infectious diseases, thus 
asserts itself as one of the most useful 
of our sciences in another direction, viz., 
that of preserving the organism against 
those diseases which, seemingly benign 
because they are recovered from, mea¬ 
sles for example, in the end shorten our 
existence by compromising the integrity 
of the organs which sustain the vital 
process itself. 

Prophylaxis and Treatment.— 
Though we are dealing with depraved 
states of a physiological condition, we 
cannot but regard them as abnormal m 
the sense that we deem adynamia abnor¬ 
mal, and, therefore, susceptible to reme¬ 
dial measures. Indeed, there is much 
that can be done in each of the three 
forms of functional hypoadrenia de¬ 
scribed. 

In the infant we should, by every pos¬ 
sible means, prevent infection or intoxi¬ 
cation to preserve the integrity of their 
adrenals and other autoprotective or¬ 
gans. The key of the whole situation 
lies in the fact that, as Ruhrah states, 
“nearly all the cases and nearly all the 
deaths are in bottle-fed babies.” Physi¬ 
cians are, as a rule, entirely too ready to 
yield to the demands of social and other 
claims put forth by mothers who do not 
wish to nurse their offsprings. The re¬ 
sponsibility assumed by both mother 
and physician under these circumstances 
is overlooked. I cannot but hope that if 
this continues, and the sacrifice of count¬ 
less infants proceeds, laws may be en¬ 
acted to prevent it by imposing upon the 
physician the duty of submitting to the 
State authorities a certificate in which 
sound reasons shall alone account for 


his consent to a departure from nature’s 
methods which entails deaths untold. J. 
Lewis Smith states that the death rate 
among foundlings in New York City 
reached almost 100 per cent, until wet- 
nurses were provided. Men such as 
Jacobi, Winters, and many French au¬ 
thorities have written forcibly upon this 
subject, but seemingly to no avail. The 
holocaust continues. 

Experimental research in the same 
direction has only served to emphasize 
the all-important prophylactic value of 
maternal milk. As L. T. de M. Sajous 
(Univ. of Penna. Med. Bull., June, 
1909) states: “That milk is capable of 
conveying antitoxic substances after 
these have been injected into the mother 
has been known for a number of years. 
In 1892 Ehrlich and Brieger demon¬ 
strated this fact in their experiments on 
mice. The offspring of non-immune 
mice were suckled by other mice which 
had been immunized against the actions 
of certain poisons. It was found that 
the young were thereby rendered im¬ 
mune to the poisons employed, viz., 
ricin, abrin, and tetanus toxin. This im¬ 
munity steadily increased during the 
period of lactation, persisted for some 
time after, and then gradually disap¬ 
peared. Ehrlich thus showed that a 
passive immunity was created in the 
young by the absorption of milk from 
an immune adult, and even went so far 
as to assert that all so-called heredity 
immunity was, in reality, of the passive 
variety, being transmitted during lacta¬ 
tion and not inherent in the offspring 
itself. 

“This transmitted immunity has been 
shown to occur in various other animals. 
Thus, in 1893, Popoff showed that im¬ 
munity against cholera could be trans¬ 
mitted through cows’ milk. He injected 
bouillon cultures into the peritoneal cav- 


438 


ADRENALS, DISEASES OF (SAJOUS). 


ity of a cow, and later injected into 
guinea-pigs from 2 to 10 c.c. of the 
cow’s milk. The guinea-pigs become 
immune against cholera. The same ob¬ 
server noted also that, when the milk 
was boiled before injecting it, no immu¬ 
nity was produced. Kraus showed that 
the milk of goats immunized by injec¬ 
tions of dyphus-coli bacilli’ and cholera 
organisms had protective and aggluti¬ 
nating properties. He also ascertained 
that the relative proportion of aggluti¬ 
nating substance present in milk to that 
contained in the serum was as 1 to 10. 
Taking up the subject from the stand¬ 
point of tuberculosis, Figari showed, in 
1905, that the agglutinins and antitoxins 
of this disease appeared in the milk of 
cows and goats that had been actively 
immunized against it. In another series 
of experiments he fed the milk of im¬ 
mune cows to a number of rabbits, and 
in others injected it subcutaneously. In 
both cases these animals, thus passively 
immunized, were found to transmit to 
their young, by their milk, the aggluti¬ 
nins and antitoxins of tuberculosis. 

“Evidence is not lacking of the trans¬ 
mission of antitoxic substances through 
human milk. It has long been known 
that infants below one year of age were 
but slightly susceptible to certain infec¬ 
tious diseases, and in particular scarlet 
fever, diphtheria, measles, and mumps. 
In fact, it was an attempt to throw some 
light on this subject that Ehrlich per¬ 
formed his classic experiments on mice 
in 1892. Four years later Schmid and 
Pflanz performed some interesting ex¬ 
periments on guinea-pigs. Into some of 
the animals they injected blood-serum 
derived from human blood which was 
taken, at the time of delivery of her 
child, from a woman to whom had been 
administered diphtheria antitoxin. Into 
other guinea-pigs they injected milk 


from the same woman. The animals 
were then given injections of the ordi¬ 
narily fatal dose of diphtheria toxin. 
From the results obtained the investiga¬ 
tors concluded (1) that antitoxin sub¬ 
stances found in the blood of parturient 
women exist also in the milk; (2) that 
the quantity of antitoxic substances ex¬ 
creted with the milk is much less than 
that found in the blood. Similarly, in 
1905, la Torre injected diphtheria anti¬ 
toxin in several wet-nurses, and noted 
the antitoxic power resulting in the 
blood of the nurslings by injecting meas¬ 
ured amounts of this blood mixed with 
diphtheria toxin into guinea-pigs. He 
was able to satisfy himself that a pass¬ 
age of the antibodies occurred in small 
amounts into the blood of the infants. 

“These experiments show, then, that 
antibodies injected into the mother are 
transmitted to the offspring. This being 
the case, it is but reasonable to expect 
that some of the protective substances 
ordinarily present in the normal moth¬ 
er’s blood should likewise reach the 
child through the milk. Experiments 
have shown this also to occur. Moro 
found that the bactericidal power of the 
blood-serum in breast-fed children was 
distinctly greater than in those arti¬ 
ficially fed. Further confirmation was 
afforded by the fact that this difference 
rapidly disappeared when the bottle-fed 
infants were put back to the breast.’’ 

The prevention of disease in the in¬ 
fant is raised to its highest standard by 
maternal lactation. The organisms of 
its gastrointestinal canal are kept under 
control; the barriers to infection that 
the respiratory tract and pulmonary al¬ 
veoli offer are well armed with antitoxic 
bodies; the blood itself is destructive to 
pathogenic organisms, and the infant is 
thus protected against those diseases 
which, even if recovered from, we have 


ADRENALS, DISEASES OF (SAJOUS). 


439 


seen, leave enfeebling lesions, fatty and 
fibrous degeneration, in those organs 
upon which his health in after years and 
the duration of his life depend. 

In the child beyond the nursing pe¬ 
riod the problem is more difficult. The 
fatal “second summer” recalls the sins 
of the milkman, the filth of the cowshed, 
and of the vessels in which the milk is 
transported and kept amply long enough 
to favor the growth of the oft-present 
Shiga bacillus, the virulent Bacillus coli, 
and even at times the streptococcus. 
The correction of these and many other 
factors replete with danger to the child^ 
and which surround it on all sides, of¬ 
fers the only resources to diminish not 
only the mortality of children’s diseases, 
but their occurrence, besides safeguard¬ 
ing health and longevity in after years. 
The good already done by our profes¬ 
sion in this direction is incalculable. 
Briefly, public, home, and school hy¬ 
giene, in the light of the facts I have 
submitted, not only serves to protect life 
for the moment when the child is con¬ 
cerned, but its entire career as a health¬ 
ful individual, while enhancing greatly 
his chances for a long life. 

It now becomes a question whether 
our resources are such as to enable us 
to raise, where functional hypoadrenia 
exists, the autoprotective resources of 
the child, sufficiently, perhaps, to enable 
it to resist infection successfully. The 
influence of many toxins and drugs on 
the adrenals points clearly to overactiv¬ 
ity under their influence. In 1903 (“In¬ 
ternal Secretions,” vol. i) I referred to 
mercury as occupying “a high position 
among the stimulants of the adrenal sys¬ 
tem.” Now, C. R. Illingworth (“The 
Abortive Treatment of Specific Febrile 
Disorders,” etc., London, 1888) and 
others have found the biniodide of 
mercury extremely efficient in aborting 


scarlatina, diphtheria, measles, variola, 
varicella, pertussis, parotitis, and many 
other infections. The great vogue of 
calomel among the physicians of the 
past generation may have found its 
raison d’etre precisely in just such an 
action—which I have myself observed. 
Arsenic is a familiar agent in the abort¬ 
ive treatment of malaria in Africa, and, 
as Surgeon-General Boudin states, in 
many other diseases. The remarkable 
results of Petresco with large doses of 
infusion of digitalis in pneumonia have 
only been tentatively explained. But if 
we realize that division of the path to 
the adrenals arrests and prevents the 
effects of digitalis, as is now well 
known, there is good ground for the be¬ 
lief that the prevailing conception of the 
action of this drug is erroneous; and that 
it is by stimulating the adrenals that it 
acts, at least in part. In view of the im¬ 
munizing action of the adrenals, there¬ 
fore, we can realize how digitalis could 
be of use in. this infectious disease, and 
how it might prove useful in aborting 
any pulmonary disorder due to patho¬ 
genic organisms. 

Very remarkable in this connection is 
the action of thyroid gland 1 grain (0.06 
Gm.), adrenal gland 2 grains (0.12 
Gm.), and Blaud’s pill 1 grain (0.06 
Gm.) in a capsule three times daily, 
previously referred to. Given during 
meals to a debilitated child of 10 or 12 
years, it seems promptly to start the 
vital machinery on a new lease of life— 
where, of course, the demands of hy¬ 
giene are adequately met. Meat is of 
value here, while milk, the fluid portion 
of which gives the test for oxidases, 
and which, as I have shown elsewhere, 
depends upon the adrenal secretion for 
its ferment (adrenoxidase) is also of 
great value. Digitalin or strychnine 
in small doses is added if the heart 


440 


ADRENALS, DISEASES OF (SAJOUS). 


is weak or to increase the oxygen in¬ 
take. All these agents tend, by keeping 
up a slight hyperemia of the adrenals 
(and of the other organs acting in con¬ 
junction with it), to augment the effi¬ 
ciency of the child’s defensive resources. 

In the adult functional hypoadrenia 
may have persisted from childhood. 
Here the measures just suggested for 
children apply as well not only as pre¬ 
ventives where infection threatens, or 
as abortive treatment, but also to raise 
the efficiency of the adrenals and the 
general health of the individual to the 
normal plane. It is probable that most 
tonics exert their beneficial influence 
through the adrenals. That “tonic” 
doses of mercury, i.e., minute doses, are 
efficient is well known; we have seen 
that it is a powerful adrenal stimulant. 
In toxic doses, in fact, as observed by 
Moline (Bull. gen. de therap., Apr. 8, 
1906), it causes intense congestion and 
even hemorrhage of the adrenals. 

While there is no doubt that meat in 
excess is harmful, it is undoubtedly 
true that, as Lorand (loc. cit., p. 313) 
states, undernutrition through lack of 
the necessary proteids in the diet in¬ 
creases the liability to infection, as I 
several years ago pointed out. Lorand 
refers to personal cases of tubercu¬ 
losis arising from a purely vegeta¬ 
rian diet. On the other hand, Richet 
and Hericourt (Lancet, Jan. 7, 1911) 
obtained remarkable effects from a diet 
of raw meat in enabling animals to re¬ 
sist tubercle infection by inoculation, 
and raw meat has become an important 
factor in the treatment of this disease. 
Grawitz (Klinische Pathologie des 
Blutes, 3d ed., 1906) also found that a 
purely vegetarian diet predisposed to 
anemia. We have seen that the ad¬ 
renals supply the blood its albuminous 
hemoglobin, a deficiency of which is an 


important feature of anemia. Did we 
live where pathogenic bacteria do not 
flourish, we might safely undertake to 
adopt vegetarian principles; but a rea¬ 
sonable amount of meat, by keeping our 
autoprotective organs, and particularly 
the adrenals, active, serves a very useful 
purpose. 

The influence of excessive fatigue on 
the adrenals, we have seen, is such as 
to weaken greatly their functional ac¬ 
tivity and, therefore, the oxygenizing 
and immunizing functions of the blood. 
The main harmful feature in this con¬ 
nection is the relative deficiency of rest, 
which means, from my viewpoint, the 
inadequate opportunity afforded the ad¬ 
renals to recuperate. This, of course, 
should be proportionate to the amount of 
strain imposed upon these organs, and 
the resistance of which they are capa¬ 
ble. It is probably owing to lack of this 
that apparently strong men are often 
the first to “give out” in forced marches. 
The physical examination being based 
mainly upon the status presens, and the 
adrenals being necessarily (for we are 
now dealing with a new line of thought) 
overlooked as factors, there is marked 
inequality in the resistance of the men 
to strain. This applies as well to the 
pathogenesis of chronic disorders. In 
a personal analysis of 40 cases of hay 
fever, for instance, the severity of the 
disease corresponded to a considerable 
degree with the number of children’s 
diseases the patient had had, the worst 
cases having had six of these diseases 
in comparatively quick succession. 

This suggests the need of ascertain¬ 
ing the number and severity of chil¬ 
dren’s and other diseases to which the 
recruit has been subjected and to add 
this factor to others in deciding upon 
his admission to the service or the arm 
to which he is to be assigned. The 


ADRENALS, DISEASES OF (SAJOUS). 


441 


mounted man suffers less from actual 
fatigue than the infantryman, who must 
carry his accoutrements, arms, car¬ 
tridges, etc., aggregating in some armies 
as much as 70 pounds. When, besides, 
defective or poor food, impure water, 
exposure, etc., and other frequent ac¬ 
companiments of a campaign are taken 
into account, one need not wonder that 
disease is a far greater factor as causes 
of debility and death than wounds. 

Briefly, fatigue should be considered, 
owing to its Inhibiting influence on the 
adrenals and the immunizing process in 
which they take part, as an important 
predisposing cause of disease. The pe¬ 
riods of rest should be so adjusted, 
therefore, as to counteract this by far 
the most destructive factor of active 
warfare. In civil life, such hardships 
are seldom endured, but here, likewise, 
much could be done to prevent infection 
by means calculated to insure the func¬ 
tional integrity of the adrenals. 

To stimulate the adrenal functions 
when marked fatigue prevails would, of 
course, only aggravate the hypoadrenia 
after, perhaps, a period of temporary 
betterment. The powdered adrenal sub¬ 
stance should, on the other hand, judg¬ 
ing from the effects of injections of ad¬ 
renal extracts in experimentally fatigued 
animals, serve a useful purpose. 

In old age the ductless glands assume 
such importance that a valuable work 
has been written by Lorand (“Old Age 
Deferred,” F. A. Davis Co., Phila., 
1910) to indicate how the functional ac¬ 
tivity of these organs could be preserved 
in order to retard the ravages of age 
beyond the fifth decade, while prolong¬ 
ing life. The reader is therefore re¬ 
ferred to Dr. Lorand’s volume for a 
mass of information which cannot be 
considered here. 

The adrenals, as shown by the plate 


opposite page 460, are deficient in circu¬ 
latory activity, and, therefore, unable to 
sustain functional activity of all organs 
up to its former standard. It becomes 
a question whether, realizing this fact, 
we should by artificial means excite the 
adrenals to greater activity. That such 
a step might shorten life instead of pro¬ 
longing it, is probable. In the first place, 
the frequent presence of arteriosclerosis 
in the aged counsels prudence; in the 
second place, to activate the adrenals 
would only hasten their degeneration by 
imposing a greater wear and tear upon 
them. Drugs capable of enhancing ad¬ 
renal activity had, therefore, better be 
avoided in the aged. 

Far better is it to compensate for the 
loss of efficiency of the adrenals by sup¬ 
plying to the blood, through a suitable 
diet, substances which contain the ad¬ 
renal principle. If my opinion that sper- 
min owes its virtues to the adrenal prin¬ 
ciple it contains is warranted, we can 
understand why Brown-Sequard reju¬ 
venated himself by means of testicular 
juice injections (I saw him at the time 
and can testify to its wonderful effects 
upon him), since he enriched his blood 
with the pabulum of oxidation, met¬ 
abolism and general nutrition, without 
impairing his adrenals. With advanced 
knowledge we need not follow his ex¬ 
ample. We have seen that milk con¬ 
tains the adrenal principle, and that all 
animal tissues owe their functional ac¬ 
tivity to its presence. In milk, butter¬ 
milk especially (since it is almost pure 
plasma), we have a ready and inexpen¬ 
sive means to compensate for deficient 
adrenal activity. If debility and other 
signs of functional hypoadrenia prevail, 
I advocate the daily addition to the plain, 
though varied, diet to which elderly peo¬ 
ple should restrict themselves of the ex¬ 
pressed juice (uncooked) of one pound 


442 


ADRENALS, DISEASES OF (SAJOUS). 


of fresh beef daily, taken in soup, if 
distasteful otherwise, and salted to 
taste. This is a powerful agent for 
good which is well borne by the stom¬ 
ach, and which more than compensates 
for the weakened adrenals, since it 
rapidly restores strength and vigor— 
provided, of course, harmful influences 
in other directions are avoided, and a 
hygienic mode of life, with reasonable 
out-of-door exercise, prevails. 

In matters sexual, aged men should 
be extremely reserved, since the waste 
of seminal fluid to them means waste of 
life substance, replaced with difficulty 
and never in abundance. 

Case of total absence of the ad¬ 
renals in a woman, aged 52, who, in 
September, 1902, noticed that her 
hands frequently became cold and 
discolored. In January, 1903, the 
joints of fingers and wrists became 
stiff and swollen; during April she 
suffered from pleurisy, and one 
month later noticed that the skin of 
the entire body was becoming darker 
(Addison’s disease), the abdomen en¬ 
larged, and she discovered a slight 
discharge from the umbilicus. The 
skin grew darker and darker (sclero¬ 
derma), The joints of the fingers 
and wrists became almost immovable 
and several of the finger-joints ulcer¬ 
ated, attended with a purulent dis¬ 
charge (Raynaud’s disease). She 
suffered intensely with the pain, cold 
and stiffness in all the joints of the 
extremities. She became emaciated 
and the whole integument became 
dry, hard, and cold. 

Under treatment with desiccated 
adrenal immediate improvement was 
noticed. The ulcerated joints healed, 
pain in them ceased, and they be¬ 
came more limber. The skin soft¬ 
ened and grew lighter. Improvement 
continued for about one year when 
the patient complained that the pow¬ 
der disturbed her stomach and re¬ 
fused to continue the drug. From 
this time she grew gradually worse 
and the previous ulcerated, stiff, cold. 


and painful condition of the joints 
returned, associated with the in¬ 
creased pigmentation and hardness 
of the skin. She died suddenly, 
December 14, 1906. At the autopsy 
no trace of the adrenals could be 
found. C. R. Love (N. Y. Med. Jour., 
Jan, 29, 1910; Jour. Amer. Med. 

Assoc., Feb. 12, 1910). 

PROGRESSIVE HYPOADRE- 
NIA. —In this condition, local lesions, 
tubercular, syphilitic, sclerous, etc., pro¬ 
gressively inhibit the functions of the 
adrenals until they fail, destroying life. 
Addison’s disease, treated separately on 
page 332 of this volume, by Professor 
J. P. Langlois, of Paris, to whose labors 

1 have repeatedly referred in the fore¬ 
going pages, is the most important syn¬ 
drome of this group. In addition is the 
group of malignant tumors which, 
though presenting the chief phenomena 
of the former and, therefore, those of 
hypoadrenia, include various symptoms 
peculiar to malignant neoplasms which 
warrant the recognition of an autono¬ 
mous syndrome complex. 

[A striking feature of tumors of the 
adrenals is their inlluence upon sex char¬ 
acters. This is common to many growths 
regardless of their nature. Thus, a large 
fibrolipoma of the adrenals among other 
abnormalities found post mortem had pro¬ 
duced in a woman of 62 (Tuffier, Bull, de 
I’Acad. de Med., May 26, 1914) changes 
which he described as adrenal virilism, i.e., 
striking masculine characters. A thick 
black beard and moustache, a masculine 
face and voice, great muscular develop¬ 
ment, with fondness for hard manual 
labor, digging, etc., and conversion of the 
clitoris into a penile organ, had all de¬ 
veloped gradually since the age of 30. 
Calais (Societe de Psychiatric de Paris, 
March 21, 1912) describes 3 similar cases, 

2 due to hyperplasia and 1 to epithelioma 
of the adrenal cortex. Changes such as 
the foregoing occur, according to the 
author, only in the female. Thus while a 
boy suffering from a sthenic growth, i.e., 
before the tumor breaks down, may grow 


ADRENALS, DISEASES OF (SAJOUS). 


443 


very large, and Herculean muscularly, the 
sexual organs being as large as those of 
an adult, which such child may resemble, 
a girl will undergo similar exaggerated 
development only for a while, then grad¬ 
ually assume masculine characters such as 
those described above. A case of her¬ 
maphroditism of this type was also 
described by Auvray (Rev. de gynec. et de 
chir. abdom., Apr., 1912) due to an adeno- 
angeio-lipoma of the left adrenal which had 
attained the size of a cocoanut. Under 
Hypernephroma in the foregoing pages 
various examples of the same kind are re¬ 
corded. C. E. deM. S.] 

CANCER OF THE ADRENALS. 

—Primary malignant tumors of the ad¬ 
renals are generally regarded as very 
rare, but it is probable that when the 
symptomatology of these growths will 
be known by the profession at large, a 
certain proportion of deaths now attrib¬ 
uted to Addison’s disease in adults and 
to asthenic disorders in children will be 
found to be due to this class of growths. 
Addison, in fact, included these neo¬ 
plasms among the etiological factors of 
the disease which bears his name, but 
it is now plain that the two syndromes 
differ in many respects, and that the 
treatments indicated—medical in the 
one and surgical in the other—impose 
the need of recognizing malignant neo¬ 
plasms of the adrenals as distinct mor¬ 
bid entities. 

VARIETIES. —Primary malignant 
tumors of the adrenals are of the va¬ 
rious forms of sarcoma, those most fre¬ 
quently met with and which occur, in 
the majority of instances, in infancy, 
childhood and adolescence; carcinoma, 
which occurs, as a rule, in adults or 
aged subjects. Among the rarer varie¬ 
ties may be mentioned the malignant 
hypernephroma and a class of tumors 
termed by Prudden hemorrhagic ade¬ 
noma. 

The sexes are affected about equally. 


but they appear much earlier in females 
than in males. Carcinoma may develop 
from hypernephroma. 

[Sixty-seven collected by Ramsay from 
literature, including 30 of sarcoma and 37 
of carcinoma. This would tend to suggest 
that the two forms occur about evenly. 
C. E. DE M. S.] 

Primary tumors of the adrenals are 
very infrequent. In the statistics of 
the Pathological Institute of Geneva, 
out of 7249 autopsies performed from 
Oct. 1, 1876, to Oct. 1, 1903, the pro¬ 
portion was 0.6 of 1 per cent. Dupraz 
(Revue med. de la Suisse Romande, 
Mar. 20, 1906). 

Study of the collection of kidney 
tumors in the Jewish Hospital at 
Berlin, 103 in all. No less than 69 
belong to the group of hypernephro¬ 
mas. In two the writer found unmis¬ 
takable evidence that true carcinoma 
had developed out of a hyperne¬ 
phroma. Displaced suprarenal ger¬ 
minal matter had lodged in the kid¬ 
ney in early embryonic existence, a 
hypernephroma had developed from 
this, and the carcinoma from the 
parenchyma of the hypernephroma. 
The writer does not maintain that 
embryonal displacement of germinal 
matter is the only cause of these can¬ 
cers, but in these cases it was evi¬ 
dently the first embryologic cause, 
without which these carcinomas 
would never have developed. The 
same applies also to some cases of 
sarcoma developing in a hyperne¬ 
phroma which are in the collection. 
The sarcoma had developed from the 
stroma. Neuhauser (Archiv f. klin. 
Med., Bd. Ixxix, Nu. 2, 1906). 

SYMPTOMS. —As a rule, the gen¬ 
eral phenomena develop insidiously, the 
adrenal lesion being well advanced when 
they begin to appear. The strength 
wanes more or less rapidly; the weight 
gradually decreases; the pulse and car¬ 
diac action become increasingly weaker 
and more rapid; the temperature shows 
exacerbation of a couple of degrees at 
times, but in the advanced cases is usu- 


444 


ADRENALS, DISEASES OF ,(SAJOUS). 


ally subnoni'al; the appetite decreases; 
digestive disturbances, such as nausea, 
vomiting, flatulence and diarrhea, are 
commonly observed. Anemia is some¬ 
times manifest, the hemoglobin being 
often reduced to 50 per cent., and the 
red corpuscles to 3,000,000 or less. 
Cough, with bronchial rales, localized 
dullness and hemoptysis are occasional 
complications, while dyspnea and in¬ 
crease of the number of respirations are 
apt to occur in advanced cases. The 
skin may remain normal, but various de¬ 
degrees of pigmentation, ranging from 
slight icterus to actual bronzing, are ob¬ 
served in the majority of cases. The 
typical facies may alone be present in 
cases of primary carcinoma. 

[This symptomatology is based on a per¬ 
sonal analysis of 60 reported cases of pri¬ 
mary malignant tumors of the adrenals. 
The phenomena are clearly explained by 
the functions I attribute to the adrenals. 
Being the purveyors of the secretion 
which—as the albuminous constituent of 
hemoglobin—sustains oxygenation and 
metabolism and, therefore, nutrition, in¬ 
creasing emaciation, weakness, hypother¬ 
mia, the decrease of hemoglobin, etc., are 
but normal results, all the other phenom¬ 
ena being secondary thereto. The cases 
in which no pigmentation of the skin oc¬ 
curs are usually those in which but one 
adrenal is involved. C. E. de M. S.] 

Case of primary sarcoma of the 
adrenal glands which did not show 
symptoms of Addison’s disease. The 
existence of the tumor was not sus¬ 
pected until after the death of the 
patient. The symptoms present sug¬ 
gested carcinoma of the stomach, 
though the more characteristic symp¬ 
toms were absent. Both adrenal 
glands were sarcomatous. Blackburn 
(Amer. Jour. Med. Sci., Aug., 1906). 

All these phenomena are seldom wit¬ 
nessed in a single case. As a rule, after 
a period of progressive emaciation and 
adynamia, a tumor can be detected by 
palpation posteriorly below the costal 


margin, close to the vertebral column. 
The mass at first follows the respira¬ 
tory movements and recedes under 
pressure, but it eventually becomes 
fixed and immovable. 

In some cases, especially in infants, 
the tumor cannot be detected in this 
manner, but the abdomen gradually 
enlarges with a steady increase of 
the line of dullness, though, perhaps, 
no other symptom be discernible. When 
the outline of the growth can be clearly 
followed with the fingers, its border is 
nodular, as in hepatic cancer, but smooth. 

Pain is sometimes complained of; it 
may be located in the region of the tu¬ 
mor ; or, radiating upward or across the 
back, it may extend to the shoulders. 

[The pain has been attributed to the 
phrenic nerve, but a clearer explanation 
is the effect of the traction by the tumor, 
upon the sympathetic ganglia and through 
the greater splanchnic, upon the sympa¬ 
thetic chain, which is merged in with the 
mass of nerves, including the brachial 
plexus, in the tissues of the shoulders. C. 
E. DE M. S.]- 

Pressure symptoms are apt to compli¬ 
cate a case of long duration. Ascites, 
general edema, or edema of the ankles 
or legs are commonly observed in such 
cases, due notably, in most instances, to 
pressure upon the inferior vena cava. 
Gangrene of the feet has also been 
observed. In carcinoma metastasis is 
most common in the liver and lungs; in 
sarcoma it is not qiute as frequent and 
occurs in most cases in the liver and 
kidney. 

Death may occur suddenly, preceded 
by very few of the above symptoms, es¬ 
pecially the sarcomata of infants. In 
the majority, however, especially in 
adults, the morbid symptoms gradually 
develop and the asthenia increases until 
unconsciousness, labored breathing and 
coma terminate in death. 


ADRENALS, DISEASES OF (SAJOUS). 


445 


Infants may also suffer from a con¬ 
genital type of adrenal tumor which 
simultaneously invades the liver. It is 
encountered as a congenital tumor dur¬ 
ing the first week of life. The abdomen 
becomes increasingly distended; there is 
moderate emaciation, but no jaundice, 
jiigmentation, ascites, or even pain, the 
child nursing almost up to the time of 
death. 

Sarcoma of either adrenal, with 
metastases in the skull observed in 
children, shows 2 entirely different 
syndromes and morbid appearances, 
according to which suprarenal is the 
seat of the primary growth. On the 
left side secondary deposits occur in 
the liver, in the ribs, and cranial 
bones, and in the thoracic duct and 
some of its tributaries. On the right 
side the primary growth usually at¬ 
tains a larger size, and more fre¬ 
quently remains localized to the ab¬ 
domen. It tends to involve the kid¬ 
neys by direct extension into their 
pelvis, stretching out the kidney sub¬ 
stance over it, but as a rule being 
easily separated. Deposits in the 
cranial bones often lead to exophthal¬ 
mos, and this usually occurs first on 
the same side as the primary growth. 
Ecchymoses into the eyelids may oc¬ 
cur and lead to confusion of the dis¬ 
ease with chloroma and infantile 
scurvy. Frew (Quart. Jour. Med., 
Jan., 1911). 

DIAGNOSIS. —The diagnosis of 
malignant tumor is not difficult when 
the tumor is sufficiently large to be dis¬ 
covered by palpation, especially when 
paresthesia over the kidney is present. 
This and the asthenic phenomena point 
clearly to the adrenals, especially if 
jaundice or any pigmentation of the skin 
be present. Unfortunately, the morbid 
process is far advanced, as a rule, when 
these signs appear. The tumor has been 
mistaken for psoitis and abscess. From 
hepatic cancer it differs in that the sur¬ 
face of the tumor is smooth instead of 


lobulated. Of course, the possibility of 
metastasis in the liver, its most frequent 
seat, must be borne in mind. Hydatid 
cyst may be suggested, but the absence 
of the hydatid thrill and other typical 
symptoms will avoid error. A project¬ 
ing and enlarged gall-bladder is some¬ 
times simulated by an adrenal tumor 
capable of displacing the intestines an¬ 
teriorly; but the latter are much less 
tense than such a gall-bladder. Ab¬ 
dominal aneurism may be suggested, 
but the absence of aneurismal bruit and 
the absence of all other signs of adrenal 
growth eliminate this source of error. 
In renal cancer or renal hypernephroma 
hematuria and other evidences of renal 
disorder are usually present, while they 
are more likely to be absent in malig¬ 
nant growths of the adrenals. Pain oc¬ 
curs earlier than in renal tumors, while 
febrile disturbance is rare in the latter. 

Two symptoms point to involve¬ 
ment of the suprarenal gland: (a) 
paroxysms of pain and paresthesias 
in the absence of a palpable tumor, 
and {b) a febrile course. The pain¬ 
ful paroxysms in renal as well as 
suprarenal tumors are due to the ex¬ 
tension of the neoplasm to the roots 
of the lumbar plexus. In suprarenal 
tumor this may occur quite early, 
owing to the immediate vicinity of 
these structures. On the other hand, 
in renal tumors the invasion of the 
capsule usually takes place at a late 
period, when the growth has reached 
so considerable a size as to become 
palpable. The fact that fever occurs 
in cases of suprarenal tumors has 
hitherto been unknown. The writer 
observed it in 57 per cent, of his 
cases, while in renal tumors it was 
present only in 1 to 2 per cent. 

Another apparently characteristic 
fact in differentiating from renal tu¬ 
mor is that the adrenal growth tends 
to approach more nearly the median 
line—in the region from the seventh 
to the ninth costal cartilages; while 


446 


ADRENALS, DISEASES OF (SAJOUS). 


the primary tumor of the kidney ap¬ 
pears first in the region from the 
ninth to the eleventh. Tumor of the 
adrenal at the time of its presenta¬ 
tion beneath the margin of the ribs 
appears broader than does that of 
tumor of the kidney, and the lower 
contour of the tumor of the adrenal 
is much less rounded than is that of 
the kidney. J. Israel (Deut. med. 
Woch., Nu. 44, 1905). 

[The emphasis laid by Israel on the 
presence of fever in adrenal malignant 
neoplasms affords striking proof of the 
correctness of my contention that the ad¬ 
renal, through the role of its secretion in 
oxidation and metabolism, was the active 
organ in fever—a process which patholo¬ 
gists have totally failed to explain. C. E. 
DE M. S.] 

Leucocythcrnia is sometimes simu¬ 
lated, but the absence of myelocytes and 
other characteristics soon eliminate this 
disease. 

Ecchymosis of the orbit of unaccount¬ 
able origin in infants and young chil¬ 
dren, or tumors of the orbit should cause 
careful search for other manifestations 
of malignant hypernephroma of the ad¬ 
renals. 

TREATMENT.—Removal is the 

only resource, but, as a rule, the result 
is unsatisfactory, owing to the fact that 
the presence of the growth is recognized 
only through metastasis; or when it has 
developed to a marked extent, and pro¬ 
duced either through metastasis, press¬ 
ure, etc., disorders in other parts of the 
organism which cannot he reached. 

Three cases of adrenal tumor 
treated by removal. One was in a 
woman, aged 47, on whom the writer 
operated in 1891, who died of recur¬ 
rence of sarcoma and exhaustion sev¬ 
eral months after the operation. The 
suprarenal growth was so firmly 
fixed to the top of the kidney that 
that organ had to be removed as 
well. The second case was that of a 
woman, aged 62, on whom he op¬ 
erated in 1897, and who is still living 


and well, the tumor removed having 
been a struma lipomatosa suprare- 
nalis, as described by Virchow. In 
this case only a wedge-shaped piece 
from the top of the kidney was re¬ 
moved with the tumor, a procedure 
followed by no morbid symptom. 
The third operation, by his colleague, 
Mr. Ward, was for a sarcoma of the 
adrenal in a child, aged 12 months. 
The child died from shock within a 
few hours. 

Of 9 cases, including his own, 5 
recovered from the operation and 4 
died. The true secret of success lies 
in operating at an early stage of the 
growth, as in the writer’s second 
case. Mayo Robson (Med. Press and 
Circular, Aug. 23, 1899). 

Removal of an adrenal myxosar¬ 
coma from a man of 50. The tumor 
weighed about seven pounds when 
removed. There was no cachexia, 
mononuclear leucocytosis or other 
symptoms pointing to the supra- 
renals. The sound suprarenal must 
have acted vicariously for the affected 
organ. The patient had recovered when 
last seen, two months after a two- 
hour operation. F. Sicuriani (Riforma 
Medica, vol. xxi. No. 44, 1905). 

Cases in which the tumor involves 
one adrenal only, as suggested by the 
absence of symptoms of adrenal insuffi¬ 
ciency, marked asthenia, emaciation, hy¬ 
pothermia, etc., and the presence of a 
tumor and hyperesthesia on one side 
only, ofifer a better chance of success, 
since they indicate that the other ad¬ 
renal will probably be able to subserve 
alone the needs of the organism. The 
chief difficulties encountered in the 
course of the operation are a marked 
tendency to hemorrhage, owing to the 
friability of the morbid tissues. 

HYPERNEPHROMA. —This 

name has been given to tumors formerly 
considered as lipomata, adenomata or 
myxomata, but shown by Grawitz in 
1883 to be developed from adrenal tis¬ 
sue, either vyithin the adrenals them- 


ADRENALS, DISEASES OF (SAJOUS). 


447 


selves or in the kidneys, the walls of 
blood-vessels or other structures in 
which “adrenal rests” (fragments of 
misplaced adrenal tissue) or “aberrant 
adrenals” occur. 

From my viewpoint, these so-called 
“adrenal rests”—found in 90 per cent, 
of all autopsies by Bayard Holmes, at 
least once a week by Grawitz in his au¬ 
topsies, etc.—are not misplaced frag¬ 
ments of adrenal tissue; they belong 
normally to the kidney. 

[I have shown (Monthly Cyclo., June 
and July, 1909) that what has been termed 
the internal secretion of the kidney is a 
product thie properties of which correspond 
with those of the adrenals, and (see “In¬ 
ternal Secretions,” 3d ed., p. 289, 1908) that 
the kidney and the adrenals were governed 
by the same nervous structures, being thus 
closely linked functionally. Under the in¬ 
fluence of centric impulses the so-called 
adrenal rests and the adrenals are both 
caused to increase their secretory activity 
and to enhance the intrinsic metabolism of 
the tissues they supply. On the whole the 
“adrenal rests” are but local aggregates of 
the chromaffin substance found in all sym¬ 
pathetic structures. C. E. de M. S.] 

Study based upon 48 hypernephro- 
mata. Thirty-four of the tumors were 
removed at operations in the Mayo 
Clinic, and 14 were unreported cases 
gathered from outside sources. The 
following general conclusions are drawn 
from this study: 1. Most, if not all, 
so-called “adrenal rests” are probably 
of Wolffian origin. 2. There is almost 
no evidence, embryolo>gical or histolog¬ 
ical, in support of Grawitz’s hypothesis 
that the so-called hypernephromata 
have their origin in adrenal rests. 3. 
There is much evidence that the so- 
called hypernephromata do arise (ac¬ 
cording to Stoerk’s hypothesis) from 
proliferations of the adult secreting 
epithelium of the convoluted tubules. 
4. There is much evidence that the 
so-called hypernephromata do arise 
from islands of nephrogenic tissue 
(primitive renal blastema). Such tis¬ 
sue is sometimes present in the adult 


kidney and appears capable of form¬ 
ing tumors of non-infiltrating mixed 
cordon, tubular, papilliform, and sar¬ 
coma type characteristic of the so- 
called hypernephromata. L. B. Wil¬ 
son (Jour, of Med. Research, Jan., 
1911). 

Hypernephromas are relatively com¬ 
mon in the kidney, constituting, as 
shown by Albarran and Joubert, 17 per 
cent, of all renal tumors; they are much 
less frequently found in the adrenals 
proper, or in other organs, such as the 
uterus, ovary, the broad ligament. Mi¬ 
croscopically they present the typical 
characters of the adrenal cortex, and 
closely, as a rule, infest vascular chan¬ 
nels. These vessels and adjacent tissues 
usually contain a colloid material simi¬ 
lar to that found in the thyroid, or se¬ 
creted by the adrenals. They are be¬ 
nign at first and become troublesome— 
sometimes after many years—mainly on 
account of their size, which sometimes 
reaches that of a child’s head, but the 
pressure they exert on surrounding 
structures, their tendency, even when 
benign, to metastasize in the lungs, 
bones, brain, give them their malig¬ 
nancy. 

SYMPTOMATOLOGY. — Before 
the local symptoms of the tumor appear 
—when any are clearly discernible—it 
evokes phenomena which are diametri¬ 
cally opposed to those of Addison’s dis¬ 
ease, and which correspond with in¬ 
creased nutrition and a stimulation of 
growth such as that produced by thy¬ 
roid preparations in cretinism. 

[This action on growth and its resem¬ 
blance to that brought about by thyroid 
overactivity has imposed itself upon in¬ 
vestigators quite independently of my own 
view—advanced in 1903 (“Internal Secre¬ 
tions,” vol. i, pp. 146-152), that it was in 
great part through the adrenals, i.e., 
through incidental stimulation of the ad¬ 
renal center by the thyroid secretion, that 


448 


ADRENALS, DISEASES OF (SAJOUS). 


the benefit of thyroid in cretinism was 
produced. The confirmatory evidence it 
affords is self-evident. The excess of ad¬ 
renal tissue which constitutes hyperneph¬ 
roma brings about the general phenomena 
of overnutrition merely because it awak¬ 
ens excessive metabolism precisely as if the 
thyroid overactivity had done so by excit¬ 
ing the adrenal center. C. E. de M. S.] 

The symptomatology varies consider¬ 
ably in different cases and suggests that 
several types exist which our present 
knowledge does not enable us to dis¬ 
criminate. Some of these exhibit such 
malignancy that they have been grouped 
in a separate class. Beginning with hy¬ 
pernephromas of the adrenals proper, 
we will first review this class of cases. 

MALIGNANT HYPERNEPH¬ 
ROMA OF THE ADRENALS.— 

This growth occurs, as a rule, between 
the first and eighth year, especially in 
girls of the latter age, and causes pre¬ 
mature development so marked, in some 
instances, that the child appears, as to 
size and development, twice or three 
times its true age. The face, genitalia, 
and pubis are covered with abundant 
growth of hair, the external genitalia 
being as fully developed as in the adult. 
The body is obese, the appetite and 
thirst excessive, although gastric dis¬ 
orders, including stubborn vomiting, are 
common. The skin may be swarthy or 
dark-hued, as in a brunette, but not 
bronzed as in Addison’s disease. Such 
children are usually cross and sullen, 
unlike obese children, in whom the obes¬ 
ity is due to deficient fat catabolism. 
These primary growths of the adrenals, 
which are usually observed in girls, are 
of slow development, and years usually 
elapse before metastasis and press¬ 
ure phenomena—those which give the 
growth its malignancy—appear. 

The abnormal growth of the child 
may suggest gigantism or acromegaly. 


due to some disorder of the pituitary 
body, but the characteristic growth of 
the extremities, the absence of obesity 
in these disorders do not occur in hy¬ 
pernephroma. An elevated temperature 
is often observed in these cases. 

[The occurrence of fever in these cases 
is clearly accounted for by my views. As 
shown in “Internal Secretions” (vol. ii, p. 
1907), the pituitary body contains the sym¬ 
pathetic center besides the adrenal center. 
During the first or erethic stage, therefore, 
the adrenals, the secretion of which sus¬ 
tains oxidation and metabolism, and which 
alone cause overgrowth in malignant hy¬ 
pernephroma, are not alone overactive, 
but the arterioles, which the sympathetic 
governs, also. The blood is not only ab¬ 
normally rich in oxygenizing properties, 
therefore, in this disease as it is in malig¬ 
nant hypernephroma, but it is also driven 
with excessive energy into the tissues, 
particularly in the long capillary loops of 
the extremities. Hence the difference be¬ 
tween the phenomena of overgrowth in 
the two diseases and the elevated tempera¬ 
ture. C. E. DE M. S.] 

Hypernephroma, whether in the ad¬ 
renal or in the kidney, contains con¬ 
siderable adrenal tissue, usually of the 
cortical type. It may provoke sexual 
phenomena. 

A study of 17 collected cases, 
showed that abnormal sex characters 
do not always attend adrenal hyper¬ 
nephroma. In children they are al¬ 
most invariably present in the form 
of hirsutes and often other abnormal¬ 
ities. In adult females before the 
menopause they are frequently pres¬ 
ent. In females after the menopause 
none is recorded, excepting a growth 
of hair on the face or change in the 
voice. In adult males they are prob¬ 
ably absent. Adrenal cortical rests 
or bilateral hyperplasia of the ad¬ 
renal cortex was noted in 15 per cent, 
of female pseudohermaphrodites, but 
in only 0.7 per cent, of male pseudo¬ 
hermaphrodites. According to the 
authors, there is no evidence that 
hypernephroma in the kidney, which 



Hypernephroma. Showing the external appearance of the kidney and tumor about 
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449 


ADRENALS, DISEASES OF (SAJOUS). 


, shows a totally different histological 
structure from that in the adrenal, is 
ever associated with abnormal sex 
characters. Glynn and Heidetson 
(Jour, of Path, and Bact., July, 1913). 

Case of a boy in whom the sexual 
development began at about 18 
months. At 10 months he could talk 
well; at 3 years his voice was that of 
a man; he had hair on the face and 
pubis, and was very strong and 
active. At 5 years and 10 months his 
facial appearance was that of a man 
of 35 or 40. Death followed soon 
after, the autopsy showing a large ad¬ 
renal tumor. J. F. Baldwin (Jour. 
Amer. Med. Assoc., Dec. 26, 1914). 

A case of hypernephroma showing 
small tumor in the anterior lobe of 
the pituitary and another in the left 
adrenal medulla with hyperplasia of 
the cortex, was described by the 
writer. While the adrenal lesion was 
suggested by marked hair growth, 
petechial hemorrhages on the hands 
and arms which became more gen¬ 
eralized and grave, those of the 
pituitary (asthenia) marked adiposis, 
extreme headaches, slight exophthal¬ 
mos, pain behind the eyeballs, in¬ 
somnia, with ultimate death from 
asthenia. The author lays stress on 
the need, owing to the interdepend¬ 
ence of the various ductless glands, 
of taking into account a polyglandu¬ 
lar syndrome. J. Anderson (Glas¬ 
gow Med. Jour., vol. Ixxxiii, p. 178, 
1915). 

Case in a girl of 3 years, in which 
a large, hard, retroperitoneal tumor 
could be felt in the left abdomen. 
Fever and increasing asthenia were 
also present. The child was some 5 
inches above the normal, and her 
physical characteristics, especially the 
genital organs, were those of' an 
adult. Death followed operation. A 
large adrenal tumor was found post 
mortem. Out of 15 cases found in 
literature by the author, the tumor 
was on the left side in 12. Van den 
Bergh (Nederl. Tydschr. v. Genesk., 
Nov. 13, 1916). 

Infants and young children are also 
subject to a form of primary malignant 

1-29 


tumor of the adrenals, described by 
Hutchinson, in which, even before the 
neoplasm, which grows with great ra¬ 
pidity, can be felt in the renal region, 
there appears a spontaneous—some¬ 
times traumatic—ecchymosis of one or 
both eyelids, soon followed by (usually 
unilateral) exophthalmos and metasta¬ 
sis in the skull, and often in other 
bones, especially the ribs. The pre- 
auricnlar lymph-nodes, and those be¬ 
hind the angle of the jaw, are enlarged, 
and the whole temporal region event¬ 
ually becomes the seat of a malignant 
growth. Pain in this location and optic 
neuritis with amblyopia may complicate 
the case. Death occurs early from 
anemia and cachexia. 

Out of 196 cases of kidney tumor 
146 were hypernephromata—that is, 
almost exactly 75 per cent. The re¬ 
maining 25 per cent, are made up 
mostly of sarcomata, to a much less 
extent of squamous epitheliomata of 
the pelvis, while a true carcinoma of 
the kidney, apart from hyperne¬ 
phroma, is a very great rarity, or, 
possibly, does not exist. The kidney 
tumors of children are practically all 
sarcomata; there is but one case on 
record of a true hypernephroma in an 
infant, and, as was long ago pointed 
out by Kiister, malignant disease of 
the kidney is a disease of earliest 
childhood and middle age, affecting 
but little young adults and the aged. 
We may conclude that hyperneph¬ 
roma is the common kidney tumor of 
adults, and that any given kidney 
tumor in an adult is much more likely 
to be one of this type than anything 
else. Trotter (Lancet, June 5, 
1909). 

Adrenal carcinoma shows two en¬ 
tirely distinct syndromes and path¬ 
ological states, according to which adre¬ 
nal is the seat of the primary tumor. 
On the left side secondary deposits 
occur in the liver, ribs, cranial bones, 
and in the thoracic duct and some of its 
tributaries. On the right side the pri¬ 
mary growth generally attains a larger 


450 


ADRENALS, DISEASES OF (SAJOUS). 


size, and oftener remains localized to 
the abdomen. It tends to involve the 
kidneys by direct extension into their 
pelves, stretching out the kidney sub¬ 
stance over it, but, as a rule, being easily 
separated. Secondary deposits occur on 
the upper surface of the liver, in both 
lungs, occasionally in the cranial bones, 
and also in the right lymphatic duct 
and some of its branches. The lym¬ 
phatics of the right suprarenal are trib¬ 
utaries of the right lymphatic duct, and 
do not, as is usually stated, follow a 
course similar to that of the lymphatics 
of the left adrenal, viz., join the lumbar 
glands. Deposits in the cranial bones 
often cause exophthalmos, this usually 
occurring first on the same side as the 
primary growth. Ecchymoses into the 
eyelids may occur and lead to confusion 
of the disease with chloroma and in¬ 
fantile scurvy. The tumor in these 
cases involves the medulla of the adre¬ 
nal, and there are reasons for believing 
that it is of carcinomatous nature. No 
pigmentation or evidence of a prema¬ 
ture sexual development, such as have 
been described as occurring in cases 
of carcinoma of the cortex of the supra¬ 
renal, were found in any of the cases 
studied. R. S. Frew (Quarterly Jour, 
of Med., Jan., 1911). 

HYPERNEPHROMA OF THE 
KIDNEY. —It is to renal growths de¬ 
veloped from the so-called “adrenal 
rests” that Grawitz, in 1883, gave the 
name “hypernephroma.” They occur 
not only more frequently in the kidnevs 
than elsewhere in the body, but consti¬ 
tute a large proportion of all renal tu¬ 
mors, i.e., 17 per cent. 

S Y M P T OMATOLOGY.— Hema¬ 
turia is often the first and the rnost fre¬ 
quently observed symptom of renal hy¬ 
pernephroma, having been noted in 90 
per cent, of all cases. The hemorrhages 
are usually severe and occur intermit¬ 
tently, weeks and even months elapsing 
between them. Worm-like clots—thus 
shaped during their passage through the 
ureters—are often passed. During the 


intervals the urine is either clear or it 
may contain red corpuscles. The hema¬ 
turia is increased by exercise and by 
manipulation of the region overlying 
the growths if the latter is sufficiently 
large to be felt. It may be the only 
symptom of the growth or precede tlie 
detection of the latter by palpation as 
much as ten years. As a rule, however, 
the tumor (which occurs in 80 per cent, 
of all cases) is sufficiently large to be 
detected much earlier, and 'sometimes 
immediately after an attack of hema¬ 
turia. It is located in the loin, often on 
the right side, and two or three finger- 
breadths below the costal margin. It is 
at first small—about the half of a wal¬ 
nut—and is movable in about one-half 
of the cases. As a rule, palpation causes 
no pain at first, though it may prove ten¬ 
der when directly pressed upon. 

Dull pain in the lumbar region, sug¬ 
gesting lumbago, may be the initial 
symptom. This pain gradually increases 
and, after being centered in the region 
of the growth, with a sensation of 
weight, increasingly radiates in various 
directions, the back, the abdomen and 
the testicles. It may come on suddenly 
and last three or four hours, then be 
followed by hematuria and frequent 
urination, followed by a period of rest, 
during which the urine is slightly albu¬ 
minous. The urine sometimes contains 
a few casts, oxalate of lime and a few 
corpuscles. During this period of rest 
a certain stiffness may be experienced 
on the side of the tumor. Varicocele is 
frequently observed in these cases, on 
the same side as the focus of pain; it 
may develop simultaneously with the 
latter and disappear when the patient 
assumes the recumbent position. 

While periodical hematuria, a tumor 
and pain in the locations mentioned are 
typical signs of renal hypernephroma, 


ADRENALS, DISEASES OF (SAJOUS). 


451 


other phenomena may appear gradually 
as the morbid process advances. Most 
important among these are the metasta- 
ses, which occasionally occur at first 
signs of the disease. This is especially 
the case in bone metastasis, which may 
appear in the vertebrae, the ribs and 
other long bones, the skull, scapula, etc., 
i.e., practically any portion of the skele¬ 
ton. Metastasis may also occur in va¬ 
rious viscera, particularly the lungs, the 
consolidation in the latter suggesting 
the corresponding stage of phthisis. 

Case of renal hypernephroma in 
which the first evidence was a metas¬ 
tasis in the upper part of the hu¬ 
merus, the only sign of the primary 
growth being an enlargement of the 
left kidney. Fifteen cases from 
literature suggested the following 
deductions in this connection: 1. A 
bone metastasis may be the first 
sign of hypernephroma. 2. A bone 
tumor in a middle-aged or elderly 
person should suggest a metastatic 
hypernephroma, for a primary bone 
tumor in elderly people is uncommon. 
3. The bone metastasis from a hyper¬ 
nephroma may be the only metasta¬ 
sis. 4. A hypernephroma may exist 
for a considerable period without 
symptoms. 5. The kidney region 
should be palpated with great care 
in every case of bone tumor. C. L. 
Scudder (Annals of Surg., Dec., 1906). 

A remarkable case was observed by 
the writers in a girl, who had begun 
to show growth of hair on the pubis 
at 1 year, and developed bodily very 
early. At the age of 7 there was a 
profuse growth of hair on the pubis, 
in the axillae, on the chin and upper 
lip. The skin of the abdomen and 
legs was rough. She was mentally 
precocious and remarkably strong. 
Her voice was coarse and deep. The 
clitoris was an inch long, half an inch! 
in diameter, and notched on the 
under surface, suggested hypospadias. 
An abdominal tumor was discerned 
, .in the right hypochondriac region, 
wUhout enlargement of the super¬ 


ficial lymph glands. At operation an 
enormous perivascular and adherent 
hypernephroma of the right kidney 
was removed, with death 3 hours 
after operation. The tumor occupied 
nearly the entire abdominal cavity. 
The uterus and ovaries were infantile. 
The. left kidney and adrenal ap¬ 
peared normal. The lungs showed a 
moderate degree of metastasis. Mic¬ 
roscopic examination of the tumor 
showed hypernephroma, with much 
tissue of the type of the adrenal cor¬ 
tex. No right adrenal body was 
found. 

Reviewing other cases previously 
reported, one of the authors notes 
that of these 18 cases, 14 were girls. 
One can differentiate these cases 
from true sexual precocity in girls by 
the presence in the latter condition of 
menstruation, enlargement of breasts 
and retention of female characters; 
and from similar conditions in boys 
by the development of the penis and 
testes. All of the 18 cases died be¬ 
fore the 16th year. Exploratory .op¬ 
eration should be done, early, even 
before a tumor is palpable; with a 
tumor present, removal is imperative. 
H. D. Jump, FI. Beates, and W. 
Wayne Babcock (Pediatrics, July, 
1913). 

Only 43 cases of occlusion of the 
inferior vena cava by a new growth 
have up to the present been accu¬ 
rately described. In 13 of these the 
growth reached as far as the right 
auricle or actually invaded it. In the 
writer’s case, a renal hypernephroma 
extended from the kidney into the 
left renal vein, traversed the inferior 
vena cava below as far as the iliac 
bifurcation and grew upward into the 
right auricle and right ventricle, caus¬ 
ing mechanical embarrassment of the 
tricuspid valve. The orifices of the 
hepatic veins were plugged with the 
tumor, and there was acute central 
necrosis of the liver from thromb¬ 
osis of the hepatic vein and -its 
branches. Sudden enlargement of 
the liver was accompanied by the on¬ 
set of acidosis, which continued until 
death, 24 hours later. Jacobson and 


452 


ADRENALS, DISEASES OF (SAJOUS). 


Goodpasture (Arch. Internal Med., 
July, 1918). 

[When adrenal tumors are sufficiently 
large to be recognized by physical exami¬ 
nation they have usually begun to break 
down, the case passing from the sthenic 
stage, when the signs are those of hyper- 
adrenm to the asthenic stage, when the 
phenomena of hypoadrenia appear: as¬ 
thenia, low blood-pressure, yellow or 
bronze pigmentation, dyspnea, cyanosis, 
etc., along with whatever symptoms the 
causative tumor may itself awaken. C. E. 
DE M. S.J 

The arteries may be thickened and 
show clearly defined signs of arterio¬ 
sclerosis, quite in contrast, sometimes, 
with the relative youth of the patient, 
and the blood-pressure be quite high. 
The skin is not bronzed in these cases, 
but yellowish, and sometimes swarthy 
or smoky, this being replaced by pallor 
when the end is near. The temperature 
may be raised, but this rarely exceeds 
1° or 2° F. 

[An important feature in this connec¬ 
tion is that bronzing is a characteristic of 
insufficiency of the adrenals, as in Addi¬ 
son’s disease, whether due to degeneration, 
tuberculosis, or malignant tumor of these 
organs or of their nerve supply. In hy¬ 
pernephroma, on the contrary, we have an 
addition of adrenal substance to the cir¬ 
culation through the secretory activity of 
the adrenal rests, as shown by the familiar 
results of adrenal overactivity enumerated 
—high blood-pressure and arteriosclerosis. 
The icterus or swarthiness here is due, 
from my viewpoint, to the continuously 
high blood-pressure which causes the cu¬ 
taneous capillaries to become hyperemic 
and to expose an increased quantity of 
the adrenal principle—the component of 
melanin (see “Internal Secretions,” vol, ii, 
p. 835) to oxidation. The stage of bronz¬ 
ing is not reached because the pigment is 
not deposited in the cutaneous tissues, as 
it is in Addison’s disease, but merely sup¬ 
plied to them in excess. C. E. de M. S.] 

The duration of the disease varies 
from fifteen weeks to eight years. The 


patient gradually loses flesh and grows 
weaker, all the symptoms become aggra¬ 
vated, hematuria becoming prominent, 
causing marked secondary anemia; 
moderate edema of the lower limbs may 
appear mainly as a result of pressure on 
some large venous trunk, and delirium 
sometimes precedes the terminal coma. 

DIAGNOSIS.—The pain in the re¬ 
gion of the affected kidney, the hema¬ 
turia accompanied by frequent urina¬ 
tion and the localized tumor, are the 
chief diagnostic points among those pre¬ 
viously enumerated, but other features 
may serve to facilitate the diagnosis. 
Gelle pointed out that fragments of the 
tumor, which is very friable and often 
dissociated during hemorrhages, could 
be found in the clots passed with the 
urine. The cells preserve their charac¬ 
ters and staining properties. 

As to diagnosis of the tumor itself 
after removal, Croftan found (1) that a 
watery extract of fresh hypernephroma, 
in keeping with adrenalin and adrenal 
extracts, provoked glycosuria when in¬ 
jected in the rabbit; (2) that a pure 
starch solution, to which the watery ex¬ 
tract of hypernephroma was added, con¬ 
tained an appreciable quantity of dex¬ 
trose; and (3) that the watery extract 
also possesses the power to decolorize 
an iodine starch solution. These simple 
tests make it possible to differentiate 
hypernephroma from other tumors of 
the kidney. This is important, since the 
post-operative prognosis of hyperne¬ 
phroma is much more favorable than 
that of any other malignant tumor of 
the kidney. A high blood-pressure 
tends greatly to insure the diagnosis. 

There are no pathognomonic signs 
of renal hypernephroma. A diagno¬ 
sis, especially in the early stages, 
must be made by a process of exclu¬ 
sion. Two personal cases, one of 
which was a boy of 14, showed ex- 


ADRENALS, DISEASES OF (SAJOUS). 


453 


tensive arteriosclerosis. This sug¬ 
gests again the importance of blood- 
pressure determinations in all cases 
where a suspected kidney lesion ex¬ 
ists. Hematuria is the most impor¬ 
tant early sign. Metastasis occurred 
in three instances as late manifesta¬ 
tions. Only two of the eight cases 
were operated upon. They have re¬ 
mained well seven and fifteen months 
respectively. H. C. Moffitt (Boston 
Med. and Surg. Jour., Oct. 8, 1908). 

A question in regard to these cases 
which has never been thoroughly in¬ 
vestigated is that of increased arterial 
tension. It is logical to suppose that, 
with an increase of adrenal tissue, we 
may have an excess of adrenal secre¬ 
tion, which would result in a rise of 
blood-pressure—certain writers have 
noted that this was true; but observa¬ 
tions upon this point sufficient to set¬ 
tle the question have not yet been 
made. Every case of hypernephroma 
should be thoroughly investigated in 
this regard, and we may find that a 
study of the blood-pressure furnishes 
us a valuable aid in diagnosis. George 
E. Beilby (Albany Med. Annals, Jan., 
1909). 

Various disorders may be suggested 
by hypernephroma, prominent among 
which is urinary calculus. In this con¬ 
nection the pain is coincident with the 
hemorrhage, while in hypernephroma 
the pain continues after the latter, 
though greatly relieved. The vermicu¬ 
lar and cylindrical shape of the clots in 
hypernephroma is also suggestive. Cys- 
toscopic examination at this time often 
reveals these clots projecting from the 
ureter of the diseased kidney, whose 
tumor can also, in some instances, be 
discerned under X-ray examination. 
Pregnancy is sometimes suggested when 
the growth projects anteriorly, espe¬ 
cially in view of the fact that amenor¬ 
rhea sometimes precedes the abdominal 
enlargement. 

Hypernephroma may be mistaken for 
enlarged spleen. The latter is usually 


nearer the surface and its mobility on 
inspiration more marked. It is located 
on the left side, whereas hyperne¬ 
phroma, in most instances, occurs on 
the right side. Catheterization of the 
ureters may serve to indicate, between 
the periods of hematuria, which of the 
two kidneys is most impaired function¬ 
ally. The blood count affords little, if 
any, information, any diminution of red 
corpuscles—sometimes to an extreme 
degree—being readily accounted for by 
hematuria. Moderate leucocytosis oc¬ 
curs in some cases, but not with suffi¬ 
cient frequency to give this sign any 
diagnostic importance. 

In some cases the symptoms and phys¬ 
ical signs, other than hematuria, afford 
but little help to establish the identity 
of the tumor, either anteriorly or pos¬ 
teriorly. In that case the absence of 
pregnancy being clearly established, an 
exploratory incision followed imme¬ 
diately, if hypernephroma be present, 
by its radical removal, is indicated. 

PATHOLOGY. — Hypernephroma 
is usually located in the upper pole of 
the kidney, immediately, therefore, un¬ 
der the adrenals. When found early in 
life at autopsies hypernephromata may 
be no larger than lentils, or even smaller, 
but they may attain the size of a child’s 
head, growing outwardly, or, in some 
cases, inwardly, at the expense of the 
renal tissues. They reproduce more or 
less perfectly, the adrenal tissue, the 
smaller growths being made up, as a 
rule, of the cortex, and the larger of 
both the cortical and the medullary sub¬ 
stance. They are firm when small, but 
when they attain a certain size their ten¬ 
dency is to become lobulated, the pro¬ 
jecting masses becoming softer and 
cyst-like. They are lobulated owing to 
the fibrous bands derived from the renal 
capsule, and the lobules, when opened, 


454 


ADRENALS, DISEASES OF (SAJOUS). 


may be yellowish, grayish red, or brown 
or blackish, and contain hemorrhagic 
areas—the source of the blood which 
causes hematuria. 

[The various colors mentioned correspond 
suggestively with the cutaneous pigments I 
have ascribed to the adrenal principle in 
icterus bronzing, etc., and this, in turn, fur¬ 
ther confirms the fact that the melanins are 
mainly composed of this principle (“Internal 
Secretions,” vol. ii, p. 835). Hence the asso¬ 
ciation of hypernephroma with melanotic sar¬ 
coma by various pathologists. C. E. de M. S.] 

The larger growths are those which 
tend to become malignant and to pro¬ 
duce metastases. These occur through 
the blood-vessels, both the arteries and 
veins; the bones and lungs, as previously 
stated, are the structures most fre¬ 
quently invaded, though, occasionally, 
extension occurs by the lymphatics, in¬ 
cluding the retroperitoneal glands. 

Microscopically they usually contain 
a scanty stroma composed of vascular¬ 
ized connective tissue in columns and a 
parenchyma formed of endothelial 
polygonal or columnar, translucent nu¬ 
cleated cells, which dififer entirely from 
those of the renal epithelium. The cyto¬ 
plasm is granular and contains, besides 
detritus and giant cells, numerous fat¬ 
laden vacuoles. It is the presence of 
considerable fat which first caused these 
tumors to be regarded as lipomata. The 
fat contains lecithin. Glycogen is also 
present, sometimes in relatively large 
quantities 

Prior tO’ 1883 many forms of renal 
growths were grouped under the head 
of lipomata. Some authors had pre¬ 
viously, and others since that time, 
described these neoplasms as adenomata 
arising from the renal tissue itself, 
Grawitz was the first to bring order out 
of chaos when he maintained that these 
growths formerly described as lipomata 
in reality had their origin in suprarenal 
tissue misplaced within the kidney. His 
reasons for believing these tumors to 


be of adrenal origin were: (1) the 
subcapsular position in which aberrant 
adrenal tissue is likely to occur; (2) 
the cells were quite different in form 
from the renal cells, and contained fat- 
globules in large drops like fatty in¬ 
filtrated liver-cells; (3) the capsule and 
the arrangement of the tumor-cells in 
rows, like the suprarenal cortex, the 
preponderance of cells over stroma; 
(4) amyloid degeneration of blood-ves¬ 
sels present in his case only in the 
adrenals. Others, like Chiari, Lubarsch, 
and many others, supported Grawitz’s 
views and added the following criteria : 
(I) the similarity between tumors of 
the adrenal body itself and these 
growths; (2) the presence of glycogen. 
The frequency with which portions of 
the suprarenal tissue are found under 
the true renal capsule and imbedded in 
the renal cortex was shown to be as¬ 
tonishingly great by Grawitz. L. L. 
McArthur and D. N. Eisendrath (Phila. 
Med. Jour., April 29, 1899). 

Four personal cases illustrating the 
stages of transition from the smallest 
benign neoplasm, a pure aberrant ad¬ 
renal germ to the large growth which 
assumes the characteristics of a cancer. 

Gradually as the malignant growth 
is approached, the adrenal germs or 
“rests” lose their normal characters to 
assume the vague embryonic cellular 
types. These correspond in every way 
with the renal cancers containing trans¬ 
lucent cells which certain classic writers 
still consider as renal cancers, but which 
in reality are hypernephromata. E. 
Gelle (L’Echo med. du Nord, Aug. 2, 
1908). 

PROGNOSIS. —As a rule, hyper¬ 
nephromata grow slowly at first, months, 
and even years, elapsing before they 
metastasize or show other signs of 
malignancy. They may then progress 
very rapidly, and, the hematuria becom¬ 
ing continuous, death occurs from 
exhaustion. 

A case was reported by Hausemann 
in a woman 60 years of age, in whom 
the tumor had been present fifteen 
years without evidence of rapid growth. 


ADRENALS, DISEASES OF (SAJOUS). 


455 


Suddenly the tumor began to grow 
rapidly and the hematuria which until 
then had been periodical and not pro¬ 
fuse, became continuous. The patient 
died of exhaustion within a few months. 
Kusmik (Beitrage zur klin. Chir., Bd. 
xlv, S. 185, 1905). • 

They show a tendency to recur, 
though years may elapse before recur¬ 
rence occurs. If recognized early, how¬ 
ever, removal afifords a greater chance 
of permanent recovery. 

Out of 4 cases, 1 of the patients al¬ 
ready reported was known to be well 
seven months after operation; another 
has remained well fifteen months, but 
the presence of a varicocele on the 
sound side renders his future doubt¬ 
ful. Dr. Levison operated on a second 
case that remained well for some years. 
Out of 24 cases with operation recorded 
by Albrecht, 8 died from the immediate 
results of the procedure and 9 soon 
afterward from local recurrence or 
metastases; 1 died of pneumonia two 
years after operation, and autopsy gave 
no evidence of recurrence. Only 4 pa¬ 
tients remained well after three years, 
and of these 1 developed metastasis 
in the occipital bone at the end of four 
years; a second, metastasis in the scap¬ 
ula after four years and three months; 
a third, metastasis in the spine after 
seven years. Only 1 patient out of 
the 24 remains well after four years. 
The danger of metastases years after 
operation renders prognosis most un¬ 
certain. Claimont has recorded a 
case of recurrence in the bronchial 
glands ten years after removal of a 
renal hypernephroma. It must be re¬ 
membered, however, that Albrecht has 
shown that there may be but one me¬ 
tastasis, and removal of this may lead 
to a permanent cure. The dishearten¬ 
ing results of operations in the 'past 
should spur on the clinician to try all 
methods that may lead to early recog¬ 
nition of the growths. H. C. Moffitt 
(Boston Med. and Surg. Jour., Oct. 8, 
1908). 

TREATMENT. — An exploratory 
incision is warranted, as previously 


stated, when an abnormal growth in the 
abdomen or in the region of the kidney 
occurs coincidently with hemorrhage, 
even when other symptoms of hyper¬ 
nephroma are not present. The ma¬ 
jority of authorities consider this pro¬ 
cedure advisable even when hemorrhage 
into the bladder cannot be accounted 
for. In some cases discomfort or ten¬ 
sion over one kidney, and deep compara¬ 
tive palpation on both sides may suggest 
which side should be explored first; but 
if this unilateral examination fails to in¬ 
dicate the presence of a growth, ex¬ 
ploration of the other kidney is justifi¬ 
able. In some instances the organ is 
merely enlarged, especially toward the 
upper pole, or at the hilum. Removal 
of the growth may be performed extra- 
peritoneally through a lumbar incision. 
The fatty capsule should, according to 
Kuzmik, be removed along with the 
growth, as it may be infiltrated and thus 
lead to recurrence. 

Case in a woman aged 37, married, 
who had an abdominal swelling the 
size of a fetal head at term. It was 
very mobile and fluctuant, and could 
not be pushed down into the pelvis. 
A diagnosis of cyst of the kidney or 
ovarian cyst with a long pedicle was 
made. On opening the abdomen the 
tumor was found to be retroperito¬ 
neal and crossed by the descending 
colon. The peritoneum was divided 
and the cyst enucleated. There was 
no pedicle. The cyst lay immediately 
in front of the left kidney, which was 
normal. The patient made a rapid 
recovery. On section the tumor con¬ 
tained blood and clots. The cyst- 
wall showed fibrous septa inclosing 
polyhedral granular nucleated cells, 
closely resembling the “zona glome- 
rulosa” of the normal suprarenal cap¬ 
sule. Archibald Donald (Brit. Med. 
Jour., Dec. 9, 1899). 

Two cases of hypernephroma, both 
of which were absolutely well one 
year after operation, a nephrectomy 


456 


AGAR-AGAR. 


AGARICIN. 


having been done at that time. Keen, 
Pfahler and Ellis (Amer. Med., Dec. 
17, 1904). 

An extraperitoneal operation can be 
done even for the removal of a very 
terge tumor, although it is possible only 
when the tumor has slowly grown into 
the tissues of the mesocolon, and the 
ventral or right peritoneal surface of 
the colon has become greatly hyper¬ 
trophied or enlarged, and the blood¬ 
vessels of the colon so distorted that a 
long incision would not, in any way, 
vitiate the blood-supply of this large 
duct. The results of a personal opera¬ 
tion also showed the necessity of taking 
advantage of every opportunity to com¬ 
pletely remove a neoplasm, no matter 
how grave the prognosis may be at the 
time of operation. Bayard Holmes 
(M«d. Standard, Nov., 1904). 

Case of hypernephroma of the left 
kidney in which the following proved 
successful: the patient having been 
perfectly well fifteen months before the 
present report. A Morris incision on 
the left side began about 2 cm. outside 
the quadratus lumborum and extended 
forward and downward to the level of 
, the anterior superior spine. This neces¬ 
sitated division of the external oblique 
muscle. The peritoneum was pushed 
forward and the kidney tumor removed 
after much difficult dissection. The 
tumor and kidney measured 18 x 10 x 8 
cm., and was densely adherent at the 
upper border. The vessels were ligated 
high Mp, and on account of the high 
position of the tumor the tips of the 
tenth and eleventh ribs were divided 
subperiosteally and the diaphragm raised 
with retractors. Most of the capsule 
was removed and the ureter was 
stripped downward, almost to the blad¬ 
der, and cut short after carbolizing the 
end. The vessels were large, but not 
occluded by the tumor mass, and were 
ligated by Pagenstecher. The peri¬ 
toneum was opened at the upper end of 
the incision, but was easily closed with 
continuous catgut sutures. The hemor¬ 
rhage was fairly severe from the cap¬ 
sule, but was readily controlled. The 
remnant of the capsule was stitched 
with catgut and a cigarette drain in¬ 


serted in the space. Muscles sutured 
with chromicized gut, skin with silk¬ 
worm gut and continuous plain catgut. 
Sterile gauze dressing. H. C. Moffitt 
Boston Med. and Surg. Jour., Oct. 8, 
1908). 

C. E. DE M. Sajous, 

Philadelphia. 

ADRIN. See Animal Extracts: 
Adrenals. 

AGALACTIA. See Mammary 
Gland. 

AGAR-AGAR is the East Indian 

name of a substance extracted from 
various seaweeds, which is available in the 
shops in the form of long, transparent 
strips resembling goose-quill pith, and also 
in quadrangular cakes weighing about 150 
grains (10 Gm.) each. It consists chiefly 
of gelose, and is soluble in hot water, 
though insoluble in cold water. It has 
been extensively used as a culture medium 
and as a demulcent, combined with glyc¬ 
erin for chapped hands and lips. 

Recently, however, it has been used for 
constipation in doses ranging from 1J4 
drams (6 Gm.) to 3/^ ounce (8 Gm.), 
coarsely comminuted and mixed with food. 
It becomes a jelly in the stomach and in¬ 
testines by absorbing water and, being in¬ 
digestible, gives considerable bulk to the 
feces, thus promoting defecation mechan¬ 
ically. A. Schmidt gives agar-agar cut up 
in small pieces, adding 25 per cent, of an 
aqueous extract of cascara sagrada. One 
teaspoonful to a tablespoonful in mashed 
potatoes or any other soft food is given 
daily in chronic constipation. S. 

Pads of agar, or agar tied in the 
center of a square of gauze, are 
recommended for the dressing of 
wounds, being very compressible and 
elastic. It absorbs 8 times its weight 
of water, and dries extremely slowly, 
while microbes and leucocytes accu¬ 
mulate in it. Loeper and Barbarin 
(Paris Med., Sept. 23, 1916). 

AGARICIN is obtained from the 
white agaric {Boletus laricis), a fungus 
growing on the trunk of the European 
larch. The activity of agaricin is due to 


AGARICIN. 


457 


agaricic, agaricinic, or agaric acid. The 
pure acid occurs as a white, silky powder 
made up of minute prismatic or lamellar 
crystals, and having a bitter taste. It is 
soluble in alcohol, and in hot water, and 
but slightly so in cold water, ether, and 
acetic acid. It forms soluble salts with 
the alkali metals. Agaricic acid is the 
preparation from agaric generally used in 
therapeutics under the name of agaricin. 
The commercial agaricin, on the other 
hand, is an impure resinous product ob¬ 
tained by extraction from the crude drug, 
and is much weaker in its effects than the 
acid. 

DOSE. —The dose of agaricic acid is Hs 
to yz grain (0.004 to 0.03 Gm.). It is 
usually given in pill form, but may also 
be administered hypodermically, when the 
dose should be one-half smaller. The 
resinous agaricin is sometimes used, the 
dose being from 1 to 5 grains (0.065 to 
0.3 Gm.). The doses given should at first 
be small; they can then gradually be in¬ 
creased as the patient becomes partially 
tolerant to the effects of the drug. 

PHYSIOLOGICAL ACTION.— Agar¬ 
icic acid in therapeutic doses decreases 
markedly the activity of the sweat-glands. 
It probably acts on the secretory nerve- 
endings to these glands (Hofmeister), thus 
resembling atropine in its action. It ex¬ 
erts, however, no inhibiting influence on 
the other secretions of the body, including 
the salivary secretion, and does not affect 
the pupils. In larger doses it causes purg¬ 
ing and sometimes vomiting by an irri¬ 
tating effect on the gastrointestinal tract. 
No serious constitutional results are ever 
produced by it when used internally-be¬ 
cause of the slowness with which it is 
absorbed. It has no cumulative action. 
Toxic effects from it may be observed, 
however, upon its intravenous injection in 
large doses into animals, and less readily 
upon subcutaneous injection. It excites 
primarily, and secondarily causes, pro¬ 
gressive paralysis of the bulbar centers, in¬ 
cluding the vagal and vasomotor centers. 
The animal shows marked weakness, be¬ 
comes dyspneic, has convulsions, and dies 
as a result of paralysis of the respiratory 
center. Subcutaneous injections of agar¬ 
icic acid produce inflammation of the sur¬ 
rounding tissues, sometimes followed by 


abscess formation. When applied to 
abraded areas or to mucous membranes it 
acts as a local irritant. 

Agaricin is a powerful poison for 
involuntary muscle, producing a 
marked and long continued rise of 
tone. It is suggested that this action 
affecting the muscular tissue sur¬ 
rounding the sweat glands prevents 
the secretion of the sweat, partly by 
more or less obstruction and by pre¬ 
venting peristaltic movements, and 
partly, perhaps, by limiting the blood 
supply. McCartney (Jour. Pharm. 
and Exper. Therap., July, 1917). 

THERAPEUTICS. —Agaricin (agaricic 
acid) is of great value in the treatment of 
the night-sweats of pulmonary tuber¬ 
culosis. Doses of Yg to Yz grain (0.01 to 
0.03 Gm.) are generally effective; accord¬ 
ing to Conkling, I/I 2 grain (0.(X)5 Gm.) will 
often suffice. Where the gastric diges¬ 
tion is good, it is well tolerated, and often 
causes diminution or even complete dis¬ 
appearance of the sweats (Andral, Legou- 
geux), especially in the second and third 
stages of the disease (Combemale). The 
action begins two hours or more after 
administration, and reaches its height 
three hours later. Taken before retiring, 
agaricin will sometimes prevent the oc¬ 
currence of a night-sweat, thereby re¬ 
lieving the patient from the consequent 
exhaustion. 

While not as certain a remedy as atro¬ 
pine, it is advantageous in not causing the 
other unpleasant effects of the latter, such 
as drying of the mouth and fauces, nausea, 
and dilated pupils. It may be given in 
combination with aromatic sulphuric acid, 
which has a similar action in reducing 
sweats. Where agaricin is found to cause 
gastrointestinal irritation and a tendency 
to diarrhea, it is sometimes prescribed 
with small amounts of some preparation 
of opium,—Dover’s powder, for example. 

Agaricin is used to counteract excessive 
sweating from other causes than phthisis, 
including various infections and intoxica¬ 
tion by certain drugs (coal-tar antipy¬ 
retics, salicylates). It has also been em¬ 
ployed to arrest the secretion of milk. Its 
action can be kept up, if desired, by re¬ 
ducing the dose previously administered, 
and giving smaH doses repeatedly. S. 


458 


AGGLUTINATION TEST. 


AGGLUTINATION TEST. 

—This test, also known as the Widal re¬ 
action or the Gniber-Widal reaction, is 
used to establish the presence of typhoid 
fever. It is based upon the fact that in 
this disease the specific bacteria in free 
dilution “agglutinate,” that is to say, ad¬ 
here to one another and lose their motile 
power, thjis forming clumps or masses in 
the solution examined. 

The essential feature of this test is that, 
while normal serum, i.e., the serum of a 
normal individual, when diluted up to a 
certain limit, will agglutinate many bac¬ 
teria besides the typhoid bacillus, the lat¬ 
ter organism causes the production of so 
great a quantity of the substance “agglu¬ 
tinin,” which provokes the phenomenon, 
that, even when a drop of serum from a 
typhoid patient is diluted 50 times or more 
with saline solution, agglutination of 
typhoid bacteria, obtained from a recent 
culture of these germs, will occur. The 
reaction is only reliable, in fact, when the 
degree of dilution is not below 1 to 50. 

The microscopic reaction requires a slide 
with a concave depression in the middle 
of one of its surfaces. A small quantity 
of the patient’s serum is obtained by prick¬ 
ing the ear or the finger. This quantity 
is diluted in fifty times its volume of 
saline solution. A drop of this is then 
placed on a cover-glass, with a drop or 
loopful of fresh bouillon of genuine 
typhoid bacilli. The cover-glass is then 
inverted and placed over the concavity of 
the slide in such a way as to cause the 
mixture to hang downward. Hence the 
term “hanging drop” method. The edges 
of the cover-glass being then sealed with 
paraffin or vaselin, the slide is examined 
under the microscope, using the one- 
twelfth oil-immersion lens, and the clamp¬ 
ing and loss of motility of the typhoid 
bacilli ascertained. If more than 4 bac¬ 
teria are permanently agglutinated, the 
test is positive. 

This method is only applicable, however, 
in hospitals, where a clinical microscope is 
available, unless the physician carries his 
microscope to the patient’s home. This 
inconvenience can be readily obviated, 
however, by dipping a piece of absorbent 
paper in the patient’s blood. When dried 
this paper can be used for the test by 


placing it in forty to fifty times the quan¬ 
tity of saline solution that the paper con¬ 
tains of serum. The latter will then dis¬ 
solve in the saline solution, and a drop of 
the mixture with the drop of typhoid 
bacilli culture can then be used as de¬ 
scribed above. 

Or again, “3 drops of blood are taken 
from the well-washed aseptic finger-tip 
or lobe of the ear, and each lies by itself 
on a sterile slide, passed through a flame 
and cooled just before use; this slide may 
be wrapped in cotton and transported for 
examination at the laboratory. Here one 
drop is mixed with a large drop of sterile 
water to redissolve it. A drop from the 
summit of this is then mixed with 6 drops 
of fresh broth culture of the bacillus (not 
over twenty-four hours old) on a sterile 
slide. From this a small drop of mingled 
culture and blood is placed in the middle 
of a sterile cover-glass, and this is in¬ 
verted over a sterile hollow ground slide 
and examined. A positive reaction is ob¬ 
tained when all the bacilli present gather 
in one or two masses or clumps and cease 
their rapid movement inside of twenty 
minutes” (Green-Hughes). 

The test may also be carried out without 
the aid of a microscope; this is the mac¬ 
roscopic reaction. Several bouillon cultures 
being available, 5 c.c. of each culture are 
placed in as many test-tubes as there are 
cultures. To each test-tube is then added 
sufficient serum of the suspected case to 
obtain a solution of 1 to 50. The test- 
tubes are then kept at blood or room tem¬ 
perature from three to seven hours. 
Their contents will then have become 
clearer, the bacilli having been precipitated 
to the bottom of each test-tube if the 
reaction is positive. It is obvious, how¬ 
ever, that the microscopic reaction is pref¬ 
erable and less liable to mislead. 

That the value of the Widal reaction is 
very great is now generally recognized. 
Kneass and Stengel in statistics based on 
over 2000 cases give 95.2 per cent, as the 
proportion in which true cases of typhoid 
fever had given a positive reaction, while 
no reaction occurred in 98 per cent, of the 
cases which eventually did not prove to be 
typhoid. Abbott, in statistics based on 
4154 cases for which the Widal reaction 
was taken in the municipal laboratories of 


AGGLUTINATION TEST. 


459 


Philadelphia, places at only 2.8 per cent, 
the possibility of error. S. 

A simplified agglutination test is 
recommended by the writer. By 
■drawing the blood direct into distilled 
water the corpuscles are destroyed, 
and the clear fluid left can be used 
just as well as the serum alone. Two 
drops of blood are drawn into 1 c.c. 
of distilled water. One drop repre¬ 
sents about 0.05 c.c. serum, and the 
dilution is about equivalent to 1 in 20. 
To the limpid red fluid 1 c.c. of saline 
is added, then dilute with saline 
sufficient to make up 1 c.c. each 
time. Control tests with the ordi¬ 
nary technic confirmed in every re¬ 
spect the reliability of this simplifica¬ 
tion of the Widal test. Liebermann 
(Deut. med. Woch., Dec. 10, 1914). 

After an experience in 275 patients, 
the writers emphasize the need for 
repeated agglutinations at intervals in 
the case at least of persons previously 
inoculated. They do not think that 
any diagnostic inference can be 
drawn from a consideration of the 
titer in inoculated persons, in cases 
in which only one examination has 
been made, as individuals vary so 
diversely in their agglutinin response 
to infection or inoculation. Donald¬ 
son and Clark (Lancet, Sept. 23, 
1916). 

The agglutination test for typhoid, 
paratyphoid A, or paratyphoid B, in¬ 
fection has not lost its diagnostic 
value as the result of prophylactic in¬ 
oculation against these infections. 
The only changes inoculation has 
produced are the need for the adop¬ 
tion of accurately quantitative agglu¬ 
tination tests, the use of a standard¬ 
ized agglutinable culture, and the 
need of repetition of the tests to 
determine the curve of agglutination. 
Walker (Lancet, Nov. 25, 1916). 

. The writer observed a multiple or 
para-agglutination of the saprophytic 
germs with various germs—those of 
the cholera vibrio, typhoid or para¬ 
typhoid, Flexner or Y dysentery 
bacilli in various combinations, etc. 

In 1 case, for example, there was ag¬ 
glutination for cholera at 1:50, for 


typhoid at 1:200, and for dysentery 
bacilli at 1: 100, with marked agglu¬ 
tination of certain bacteria found 
which are not usually regarded as 
pathogenic. Baerthlein (Miinch, med. 
Woch., Oct. 31, 1916). 

The writer made intracardiac, and, 
in 2 cases, intravenous injections of 
an agglutinin so strong that it could 
be detected in minute quantities. He 
found that in general a foreign serum 
disappears more quickly from the 
blood of an animal sensitized to that 
serum than from that of a normal 
animal. It disappears more quickly 
from the blood of highly reacting 
animals than from that .of slightly 
reacting animals. Hempl (Jour, of 
Immunology, Feb., 1917). 

The following simple and rapid 
macroscopic method is suggested for 
the application of Moss’s test: Using 
citrated Serum II and Serum III, 
made to contain 1.5 per cent, of 
sodium citrate to prevent coagulation 
of the blood to be added, and pre¬ 
served with 0.25 per cent, tricresol, a 
glass slide is prepared by placing one 
or two drops of Serum 11 on its left 
end and an equal amount of III on 
the right end, then two small drops 
of the blood to be tested are secured 
from a finger prick and mixed with 
the two serums. A positive agglu¬ 
tination is shown by clumping of the 
red cells which occurs within less 
than a minute and which is easily 
seen by the naked eye. The group 
number of the corpuscles is readily 
determined from the combination of 
reactions in the two tests by compar¬ 
ing the slide with the two middle 
columns of the following table. 


Relation of the Four Blood Groups. 




Corpuscles 

_ Spriim 



Group 

: T 

II 

III 

IV ' 


I .. 


+ 

+ 

+ 

I 

II .. 


0 

+ 

+ 

II 

Ill .. 

.... o 

+ 

o 

+' 

III 

IV ... 


o 

o 

o 

IV 


I 

II 

III 

IV 


Beth 

Vincent (Jour. Amer. 

Med. 


Assoc., Apr. 27, 1918).- 







460 


AGORAPHOBIA. 


AGURIN. 


AINHUM. 


Active convection currents in tubes 
increase the rapidity of agglutination 
materially, especially in bacterial sus¬ 
pensions which agglutinate rather 
poorly. Convection currents are best 
secured by immersion of the agglu¬ 
tination tubes in the waterbath at 
55° C. until the water rises to only 
% to ^ the height of the column of 
fluid tested. This technique gives 
uniform results and materially short¬ 
ens the time of incubation. Topley 
and Platts (Lancet, June 8, 1918). 

S. 

AGORAPHOBIA. —This term is 

applied to a variety of obsessions in which 
fear of not being able to cross an open 
space, a room, street, square, etc., pre¬ 
dominates. The patient carries out the 
act, however, when compelled to do so, 
or in company. He may be quite normal 
otherwise, though condemned to a seden¬ 
tary life. It is often associated with acute 
neurasthenia, and occasionally with the 
chronic form of this disease. 

AGURIN, a diuretic, is a double salt of 
theobromine sodium and sodium acetate, 
which contains 60 per cent, of theobro¬ 
mine. It occurs in the form of a fine 
crystalline powder, which is freely soluble 
in water, and but slightly so in cold 
alcohol. 

MODES OF ADMINISTRATION.— 

Agurin is hydroscopic and, in aqueous 
solution, readily splits into its components. 
Hence, the advisability of prescribing it in 
capsules or in tablets, 5-grain tablets be¬ 
ing available in the shops. The dose is 
from 5 to 10 grains (0.3 to 0.6 Gm.) three 
to five times a day. It is also absorbed 
from the rectum when given in an enema 
of plain water. 

THERAPEUTICS. —Agurin is espe¬ 
cially efficacious as a diuretic in cardiac 
dropsy and acts well in combination with 
digitalis. It acts like theobromine (g.v.) 
and is, unlike diuretin, well borne by the 
stomach. It also gives good results in in¬ 
terstitial nephritis, especially when com¬ 
bined with the milk diet. This applies 
also to hepatic cirrhosis, though to a less 
marked degree. Agurin presents the ad¬ 
vantage of promoting diuresis without in¬ 


creasing the blood-pressure, a property 
which renders it particularly useful in 
cases of dropsy of cardiac, renal, or 
hepatic origin in which arteriosclerosis 
renders diuretics which raise the blood- 
pressure dangerous. S. 

AINHUM. — African word meaning 
“to saw off.” 

DEFINITION. —Ainhum is a disease 
occurring exclusively in negroes and con¬ 
sisting in the spontaneous amputation of 
the little toe by an adventitious fibrous 
band. 

SYMPTOMS. —The first indication of 
the disease is a furrow on the lower sur¬ 
face of the little toe, and occasionally 
other toes, at the proximal interphalangeal 
joint. This furrow, the result of the cir¬ 
cumferential pressure exerted by a fibrous 
ring, gradually deepens until the bone is 
reached, this process taking several years, 
sometimes as many as ten. The distal 
portion of the toe becomes greatly hyper¬ 
trophied, then finally drops off, the stump 
healing without further complications in 
the great majority of cases. It does not 
give rise to much suffering, owing to its 
very gradual progress. It is sometimes 
mistaken for leprosy. It has been ob¬ 
served in the white race also. 

Though rare in the United States, 
ainhum is so common in India that 
Crawford found a case in every two 
thousand surgical patients in Indian 
hospitals. The absence of pain or 
inconvenience in many cases also 
probably prevents their being re¬ 
ported. The ultimate result of the 
disease, which begins as a crack or 
fissure, is the spontaneous amputa¬ 
tion of one or more fingers or toes 
by a gradual circular strangulation. 
In the writer’s case, complete ampu¬ 
tation of one toe and partial amputa¬ 
tion of another had occurred before 
the patient sought medical assistance 
or appreciated his condition. It is 
fare in females, and is almost ex¬ 
clusively confined to the dark-skinned 
races, only 4 cases having been re¬ 
ported in whites. It is probably a 
trophoneurosis of unknown origin. 
N. D. Brayton (Jour. Amer. Med. 
Assoc., July 8, 1905). 


b . 

•AINHUM. 


461 


Case of ainhum in a white girl in 
Florida. The case is of interest be¬ 
cause of the appearance of ainhum 
in the Southern States and heretofore 
reported in the negro race only. 
When ulceration takes place the ulcer 
assumes a resemblance of a necrotic 
ulcer with a distinct nauseous color. 
As advanced by Unna, the condition 
is a sclerodermic callosity, with ring 
formation, producing a stagnating 
necrosis. The tumefaction indicates 
a stagnation, resulting in degenera¬ 
tion, retraction, and finally disappear¬ 
ance of the phalanges. The disease 
sometimes covers a period of several 
years. Eskridge (Med. Rec., Sept. 17, 
1910). 

Two cases of ainhum that the 
writer has cared for at Garfield Hos¬ 
pital Dispensary. He watched the 
progress of the case for two years, 
and showed photographs and skia¬ 
graphs of them, taken at the begin¬ 
ning and end of observation. One 
case, in a negress, a native of Mary¬ 
land, was of sixteen years’ duration, 
but only slightly advanced. The pain 
in the crack was, however, sufficient 
to induce her to have the toe ampu¬ 
tated. The specimen showed the 
groove in the soft tissues and the 
slight atrophy of bone. 

The other case, also in a negress, a 
native of Georgia who had lived 
fifteen years in the District of Colum¬ 
bia, was of about twenty-five years’ 
duration and much more marked than 
the other case; the groove around the 
toe was deepest on the plantar and 
inner margins of the toe and had 
penetrated almost to the toe-nail. 
The middle phalanx was practically 
gone; only the nail-bearing part of 
the ungual phalanx remained; the 
basal phalanx was atrophied about 
one-half. The advance of absorption 
of bone was quite plain in the skia¬ 
graphs. The skin of the feet and 
hands showed a scaly condition. As 
the toe had given but little pain, the 
patient declined to have it amputated, 
and had therefore come for treatment. 
Truman Abbe (Washington Med. 
Annals, Nov., 1910). 


ETIOLOGY. —Ainhum is always ob¬ 
served in negroes, especially of the west¬ 
ern coasts of Africa and South America. 
A number of cases have also been reported 
in the United States by Bringier. Hin¬ 
doos are said to also suffer from the dis¬ 
ease. Self-mutilation has been suggested 
by some observers, but the likelihood of 
this cause is very slight. Heredity does 
not seem to play any role in its production. 

PATHOLOGY. —The lesions observed 
have been hypertrophic thickening and 
retraction of the derma, with consequent 
atrophy of the underlying bone (Hermann, 
Weber, Wucherer, Schiippel). It has been 
confounded with congenital amputation, 
but, as stated, ainhum is never congenital. 
That the disease bears some connection 
with leprosy is insisted upon by some 
authorities. According to Zambaco, Pacha, 
undoubted symptoms of leprosy are pres¬ 
ent in all cases of true ainhum. It should 
be looked upon as an attenuated form of 
the latter disease. Its relations to sclero¬ 
derma are explained by the fact that this 
latter affection is a special form of leprosy. 
It has also been attributed to syphilis, 
larvae, and atavism. 

The writer agrees with Matas in 
terming ainhum a trophoneurosis. 
Personal case in a negress of 65 
years whose right little toe was 
affected in the characteristic way. 
The toe was disarticulated at the 
metatarsophalangeal joint under co¬ 
caine anesthesia, and the cicatrix has 
since remained in healthy condition. 
H. N. Blum (Med. Record, Oct. 22, 
1904). 

No definite and undisputed cause 
for the lesion has yet been proved, 
but the writer thinks that there is 
most to be said in favor of de Silva 
Lima’s' view that it is due to trau¬ 
matism, The splay-footed negro is 
especially liable to such, and the 
groove around the toe in this disease, 
both macroscopically and histologic¬ 
ally, is a cicatrix. The later fatty and 
atrophic conditions in the amputated 
toe are not yet fully explained, but 
may depend on local cicatricial forma¬ 
tions or may be of trophic origin. 
Wellman (Jour. Amer. Med. Assoc., 
March 3, 1906). 


462 


AIROL. 


ALBARGIN. 


TREATMENT. —Surgical measures alone 
prove of value in these cases. Early sec¬ 
tion of the fibrous ring is sometimes suffi¬ 
cient to arrest the progress of the disease, 
or division of the skin down to the perios¬ 
teum on the opposite side of the seat of 
the disease may be resorted to. 

Murray successfully treated a case by 
dividing the skin and all the tissues down 
to the periosteum, on the side opposite to 
the seat of the disease. S. 

AIROL, or bismuth oxyiodogallate 
IC 6 H 2 (OH) 3 .COO.BiIOH], is a compound 
of gallic acid and bismuth subiodide. It 
occurs in the form of a bulky, grayish-green 
powder, devoid of odor or taste. It is in¬ 
soluble in water, alcohol, chloroform, and 
ether, but is slightly soluble in glycerin and 
is dissolved in alkaline solutions and dilute 
mineral acids. When exposed to moisture, 
including wound secretions, it is gradually 
changed into a reddish powder, due to the 
liberation of a portion of its iodine: this 
change occurs with great rapidity when boil¬ 
ing water is applied to airol. 

MODES OF ADMINISTRATION.— 
Internally airol has sometimes been given in 
doses of 2 to 5 grains (0.13 to 0.32 Gm.). 
Externally it is used principally in the 
powder form, which is dusted over the sur¬ 
face involved after it has been washed with 
hydrogen peroxide or other cleansing agent. 
It may also be applied in an ointment con¬ 
taining about 2 to 4 drams of airol to the 
ounce of petrolatum, or in a 10 per cent, 
glycerin emulsion containing equal parts of 
glycerin and water. The latter preparation 
may be injected in septic areas. In the 
treatment of skin lesions it has been applied 
as a paste containing 2 parts each of glyc¬ 
erin and mucilage tO' 1 part of airol, mixed 
with a sufficient amount of refined clay or 
kaolin (Brun’s paste). Airol has also been 
used as a vaginal suppository. An airolated 
gauze (20 per cent.), similar to iodoform 
gauze, is frequently employed. The fact 
that this substance is decomposed by free 
contact with water should always be kept in 
mind. 

PHYSIOLOGICAL ACTION.— When 
used internally or by injection in large 
amounts, airol has been known to cause 
symptoms similar to those of bismuth poison¬ 
ing. Thus Semmer witnessed a case in 


which 55 grains of airol as a 10 per cent, 
solution in olive oil injected into an abscess 
resulted within three days in softening of 
the gums, darkening of the buccal mucous 
membrane, foul breath, headache, nausea, 
and prostration. Marked irritative effects 
have also been observed (Zelemsky, Gold- 
farb), though a total amount of 15 grains 
taken within three days was found by 
Haegler to cause no unpleasant effects. 

THERAPEUTICS. —Airol is valuable ex¬ 
ternally as an antiseptic, astringent, desic¬ 
cant, and protective. Its germicidal prop¬ 
erties are mainly due to the liberation of 
iodine upon exposure to moisture. 

Haegler considers airol the equal of 
iodoform in disinfecting power, and it has 
the added advantage of being without 
odor. It is frequently used as an antiseptic 
dressing for open wounds, including sur¬ 
gical wounds, and generally causes no pain 
when applied. It has been applied to in¬ 
fected ulcers of different kinds, varicose 
ulcers (Fahm), burns of the second degree, 
and to the lesions of various skin diseases, 
such as intertrigo (de Sanctis), etc. It has 
proven useful when injected with glycerin 
in abscesses of pyogenic or primarily 
tuberculous origin. 

In ulcerations of the cornea, airol has 
been applied in powder form with success 
(Gallemaerts, Bonivento). 

Airol has been used for the treatment of 
uterine and vaginal inflammations. It may 
be incorporated in ihe usual cocoa-butter 
suppositories for vaginal use, or introduced 
into the uterus and vagina on gauze moist¬ 
ened with a liquid mixture. Delbert dips a 
wick of aseptic gauze in a 1 to 4 emulsion of 
airol in glycerin and inserts it through the 
previously dilated cervix into the uterine 
cavity; he then packs the vagina with 
- tampons of absorbent cotton dipped in a 1 to 
20 emulsion, and does not remove it for 
forty-eight hours (Manquat). 

Airol may be given where an astringent 
effect on the intestinal tract is desired. 
Fahm has recommended its use in tuber¬ 
culous enteritis. S. 

ALBARGIN, or gelatose silver, an 
antiseptic and germicide, is a compound 
of silver nitrate 15 parts and gelatose 85 
parts. It -occurs as a light, brownish-yel¬ 
low, shining powder, which is freely solu- 


ALBUMINURIA (LEVISON AND ERLANDSEN). 


463 


ble in equal parts of both cold and hot 
water, making a permanent solution if not 
exposed to light. It is incompatible with 
ferric and ferrous chlorides, tannin, opium, 
resins, and the essential oils. 

THERAPEUTICS. —Albargin is mainly 
used as a substitute for silver nitrate in 
the treatment of gonorrhea. Its aqueous 
solutions being neutral, it may be used as 
injections in strengths from ^2 to 2 per 
cent. Its molecule being smaller than that 
of albuminous preparations of silver, it is 
thought to penetrate more thoroughly and 
promptly the diseased tissue and destroy 
the gonococci therein. Albargin has also 
been found efficacious in the treatment of 
chancroids. Its use is painless, and it does 
not irritate mucous membranes; it may 
safely be used, therefore, in the treatment 
of gonorrheal ophthalmia. S. 

ALBUMINURIA.— D E F I N I - 
TION. —The presence of albumin in 
the urine, a condition now known 
to occur under many circumstances 
without necessarily indicating the 
presence of serious morbid changes 
in the kidney. 

Albuminuria may be true —when the 
albumin is dissolved in the urine—or 
spurious, when caused by admixture of 
semen, pus, or blood in the urine. 
Spurious albuminuria is easily dis¬ 
tinguished from the true form by 
the aid of the microscope. Both 
kinds of albuminuria may occur 
simultaneously. 

Domenico Cotugno discovered, in 
1770, that urine may contain albumin; 
by boiling a sample of urine he found 
that pure albumin was precipitated. 
It was long maintained by all authors 
that albuminuria was always a symp¬ 
tom of disease, but of late many 
authorities have admitted that albu¬ 
minuria may be compatible with per¬ 
fect health. 

Posner maintains that albumin is 
always found in the urine, but 


normally in too small quantity to be 
revealed by the ordinary reagents. 
To demonstrate the presence of albu¬ 
min in normal urine Posner evapo¬ 
rated large quantities of urine at low 
temperature and tried the different 
reagents in the concentrated urine. 
His experiences were repeated and 
his views supported by Senator and 
by Leube, who, however, did not 
find albumin in all cases. Von Noor- 
den, Winternitz, Lecorche, Talamon, 
and other authors do not admit that 
albumin is a constituent of the normal 
urine; but this was recently denied 
by Morner, who found that it inva¬ 
riably contained at least 22.78 mg. 
(about 3.5 of a minim) per liter. 

Different kinds of albumin may be 
present in the urine; generally the 
proteids contained in the blood-serum 
are to be found,—viz.: (1) the serum- 
albumin, and (2) the globulin, or 
paraglobulin; in most cases both these 
proteids are present, but in varying 
proportions. In some cases there may 
also be found (3) hemialbumose, or 
propeptone, a mixture of different albu- 
moses which are not precipitated by 
boiling; (4) nucleoalbumin, which has 
also erroneously been called “mucin,” 
and (5) peptone. Joachim found pseu¬ 
doglobulin in every case of albuminuria, 
while euglobulin was often absent. The 
albumin content mostly exceeds that of 
the globulin. 

The urine may, of course, also 
contain albumin in connection with 
hematuria and hemoglobinuria, but 
such cases cannot be classed as true 
albuminuria. 

PHYSIOLOGICAL A L B U MI - 
NURIA. —Regarding the origin of 
the albumin in the urine only guesses 
can be made; two theories are pos¬ 
sible: (1) the albumin may come from 


464 


ALBUMINURIA (LEVISON AND ERLANDSEN). 


the glomeruli; (2) from the tubular 
epithelial cells. 

Formerly the opinion predominated 
that the fluid which escaped from the 
glomeruli was albuminous, but that the 
albumin was absorbed during the pas¬ 
sage through the healthy renal tubules, 
diseased tubular epithelium being un¬ 
able to absorb the albumin. This has 
not been proved, however, and most 
modern authors believe that albumin is 
not contained in the urine coming from 
the glomeruli, except when these are 
diseased or when the pressure of blood 
in the glomeruli is abnormally great. 
Runeberg, on the contrary, is of the 
opinion that albuminuria is caused by 
low pressure of blood, and supports this 
opinion by experiments with animal 
membranes, but experiences with dead 
membranes cannot be regarded as con¬ 
clusive for the action of the living 
kidney. 

Von Noorden and other authors re¬ 
gard the tubular epithelium as the 
unique source of albuminuria. These 
epithelial cells are subject to successive 
disintegration: when this is minimal, 
and successive traces, only, of albumin 
are found in the urine, the albuminuria 
is physiological; when the disintegra¬ 
tion of the tubular epithelial cells is 
augmented and hastened by disease, a 
morbid albuminuria takes place. In 
his opinion, this theory is supported by 
the fact that nucleoalbumin, of which 
the protoplasm of the cells undoubtedly 
is the source, is always found in nor¬ 
mal urine. 

Benign albuminuria depends, ac¬ 
cording to the writer, on a vagatonia 
which is itself due to a reduced tonus 
of the sympathetic caused by aplasia 
and insufficiency of the chromaffin 
system. In vagatonia the renal ves¬ 
sels are constantly dilated because of 
the decreased tone of the sympa¬ 


thetic. When, in a person so affected, 
a greater quantity of adrenalin is 
secreted because of any reason what¬ 
ever, the reduction of tone of the 
sympathetic becomes still greater, 
and consequently the dilatation of 
the renal vessels becomes so great as 
to give rise to renal stasis and so to 
an albuminuria. C. v. Dziembowski 
(Berl. klin. Woch.; Corresp. blatt f. 
schweizer Aerzte, Jan. 19, 1918). 

Senator considers physiological al¬ 
buminuria in the same light as physio¬ 
logical glycosuria, and, among the 
causes that give rise to it in susceptible 
individuals, he mentions: severe exer¬ 
tion of the lower extremities, eating 
and digestion of hearty meals, men¬ 
struation, cold baths, psychical excite¬ 
ment, etc. He deems. albuminuria 
pathological only when it does not 
disappear promptly on the cessation 
of the particular stimulus that caused 
it. Physiological and allied forms of 
albuminuria are attributed to con¬ 
genital predisposition of the individ¬ 
ual to disease of any organ which 
directly or indirectly may influence 
the elimination of albumin. 

The influence of exertion was 
shown on 528 soldiers by the writers. 
Of these 56, or 10.6 per cent., had 
albuminuria. The amount of albumin 
was small in the great majority. To 
determine the influence of work and 
rest on the excretion of urine, the 
latter was examined immediately 
after work, and in the morning after 
a night’s rest. It was found to be 
present in 11.5 per cent, after work¬ 
ing, in 7.9 per cent, after rest. M. 
Laber and P. Lauener (Corresp. Bl. 
f. schweizer Aerzte, July 24, 1915). 

In soldiers the writers found com¬ 
plications in the kidneys directly 
after acute infectious diseases in 17 
per cent, of the men examined, irre¬ 
spective of whether the men had been 
serving at the front or had never 
reached the trench line. In 6 of 18 
men the albuminuria had developed 


ALBUMINURIA (LEVISON AND ERLANDSEN). 


465 


after acute tonsillitis. There was a 
history of some old acute infectious 
disease in 40 per cent, of the eighty 
men from the front and in 50 per 
cent, of the thirty others. In 22 per 
cent, there was primary nephritis oc¬ 
curring in previously healthy men. 
In two of the men the albuminuria 
developed after antityphoid vaccina¬ 
tion. Chronic albuminuria which may 
be well borne in civilian life is ex¬ 
tremely liable to give trouble under 
the stress of military life. Merklen 
(Annales de Med., May-June, 1918). 

From a pathological point of view the 
causes of albuminuria may be divided 
into three groups: 1. Disturbances of 
circulation. 2. Changes of the tubular 
epithelial cells or of the walls of the 
blood-vessels of the kidney. 3. Changes 
in the composition of the blood. 

1. All disorders of circulation capa¬ 
ble of causing a venous renal congestion 
will increase the blood-pressure in the 
capillaries of the kidney, and thus give 
rise to a transudation of albuminous 
liquid; when the congestion is very 
great the urinary tubules may even be 
compressed and the escape of the urine 
rendered difficult. When this is the 
case and when, also, the supply of 
arterial blood is diminished, the tubular 
epithelium will be damaged, and the 
first result of all this is albuminuria. 
It is very improbable that arterial con¬ 
gestion ever produces albuminuria, al¬ 
though the experiments of Munk and 
Senator tend to prove the contrary. 
Leube found in the early stages of 
aortic insufficiency, not accompanied by 
cyanosis, edema, etc., a slight albumi¬ 
nuria. Pathological examination of the 
kidneys showed the walls of arteries 
and capillaries much thickened. He 
makes these changes and their conse¬ 
quences responsible for the maltnutri- 
tion of the kidney and its result: 
albuminuria. 


2. Changes of the tubular epithelia 
and the walls of blood-vessels of the 
kidneys may, as already stated, be due 
to disorders of circulation, but they may 
also be caused by different poisons and 
toxins. When albuminuria is chiefly 
caused by degeneration of the tubular 
epithelia, their protoplasm dissolves in 
the urine, and nucleoalbumin in great 
quantity is contained in it, combined 
with serum-albumin and globulin. 

Menge and Schreiber noted albumi¬ 
nuria in several cases in which the 
kidney had been palpated bimanually, 
as a result of the circulatory changes 
produced during the examination. This 
procedure has been used by Schreiber 
in the diagnosis of doubtful cases of 
floating kidney. 

3. When the composition of the 
blood is altered, the urine often becomes 
albuminous. This can be proved ex¬ 
perimentally by injecting egg-albumin, 
soluble casein, hemoglobin, etc., into 
the veins of animals; the quantity of 
albumin excreted after the injection 
will generally exceed the quantity in¬ 
jected. Similar results may be obtained 
by the injection of peptone and propep¬ 
tone, whereas the albuminates are gen¬ 
erally inoffensive. Ingestion of a very 
large quantity of egg-albumin is liable 
to provoke albuminuria. 

Semmola has tried to prove that albu¬ 
minuria is always caused by changes of 
the blood characterized by abnormal 
diffusibility of its proteids, and, in his 
opinion, the pathological changes in the 
kidneys are consecutive to the albumi¬ 
nuria. Though his theory is not gener¬ 
ally accepted, Rosenbach has adopted it 
for the albuminuria which is not caused 
by nephritis, and regards it in such cases 
as a salutary and regulating process, if 
such can occur at all. 

In most clinical cases different causes 


1—30 


466 


ALBUMINURIA (LEVISON AND ERLANDSEN). 


are simultaneously active, and it is 
generally very difficult to determine 
which is the preponderating etiological 
factor. L. Williams ascribes the ma¬ 
jority of cases of albuminuria either to 
altered blood states or to failure in the 
normal vasomotor mechanism. 

The majority of the cases are due to 
either altered blood states or to failure 
in the normal vasomotor mechanism. 
This failure, may manifest itself in one 
or two directions. In the first, chiefly 
by some means so far undiscovered, the 
blood-pressure in the splanchnic area 
arises and is maintained at a suffi¬ 
ciently high level to induce a renal 
plethora and consequent albuminuria. 
Of such are the cases of hyperpiesis, 
as in the instance quoted. In the sec¬ 
ond place, owing to a local or general 
vasodilatation, the blood-pressure in the 
splanchnic area falls to the point at 
which a renal stasis is induced. Of 
such are the cases of cyclical, postural, 
and athletic albuminuria, of which also 
instances are cited, cases which, for the 
most part, occur in young adults in 
whom the vasomotor response is either 
undeveloped or for some reason is in¬ 
adequate. Having regard to these 
facts, the writer ventures once more to 
insist not only that, of itself, albumi¬ 
nuria affords no evidence of renal dis¬ 
ease, but that, of itself, it does not 
present even a reasonable suspicion of 
the existence of such disease any more 
than, of itself, dyspnea presents a rea¬ 
sonable suspicion of cardiac disease. L. 
Williams (Clin. Jour., Apr., 1908). 

It is, nevertheless, true that traces of 
albumin, and even a rather considerable 
amount of it, may be found in the urine 
of persons otherwise healthy and pre¬ 
senting no symptoms of disease of the 
kidneys or of the organs of circulation. 

Many clinicians, therefore, admit 
that albuminuria may be regarded, in 
some cases, as physiological; this is, 
however, contested by many. 

Case in which for over twenty years 
the patient had been passing large 


quantities of albumin in the urine, 3 
grams per liter. Microscopic examina¬ 
tion revealed no casts or corpuscles, 
and there was nothing to suggest renal 
trouble. The heart was normal in size, 
the sounds were normal, blood-pressure 
was in the limits of the normal, and 
there was little or no arterial thicken¬ 
ing. The patient has maintained his 
usual high standard of health, and, al¬ 
though he had always been thin and 
spare, he is very tough. The most re¬ 
markable feature of the case, however, 
is that all the members of the patient’s 
family exhibit the same peculiarity. 
They are all perfectly well, and, con¬ 
sidering the age the parents have at¬ 
tained (87 and 78 respectively), such a 
case as this should have an important 
bearing on the question of rejection or 
“loading” of candidates for life insur¬ 
ance. Fergusson (Brit. Med. Jour., 
Mar. 19, 1910). 

Virchow described a physiological 
albuminuria in infants, occurring in 
the first days of life, and explained 
it by the sudden changes of circula¬ 
tion taking place immediately after 
delivery. 

Flensburg and Sjoquist have shown 
that albuminuria regularly occurs in 
the first days of life, and that the 
urine also contains an extraordinary 
quantity of uric acid crystals; prob¬ 
ably the albuminuria is then due to 
the irritation of the kidneys caused 
by these crystals. Ebstein and 
Nicolaier have shown experimentally 
that when the kidneys are forced to 
excrete a surplus of uric acid which 
cannot be dissolved, but goes to the 
bottom in the form of crystals, the 
urine commonly contains albumin 
and sometimes even blood. 

Gull found a certain form of physio¬ 
logical albuminuria in adolescents 
about the age of puberty, especially 
in weak and pale individuals. Other 
authors, among whom is Quain, have 


ALBUMINURIA (LEVISON AND ERLANDSEN). 


467 


noticed that this condition is quite 
frequently associated with masturba¬ 
tion. 

Lommel found that 19 per cent, of 
young men (14 to 18 years old) suf¬ 
fered from albuminuria without hav¬ 
ing nephritis. The albuminuria had 
an intermittent character and was 
orthostatic in type. 

Dunhall and Patterson and Collier 
found albuminuria (0.2 to 15 per 
cent.) after severe exercise (such as 
rowing and running in races) also in 
healthy subjects. 

Albuminuria is of fairly constant 
occurrence in patients who have 
acute or chronic suppuration. If an 
abscess is deep and under consider¬ 
able pressure, albuminuria is more 
likely to occur. If the abscess is 
drained, the albuminuria disappears. 
Marcozzi (Folio Urologica, Feb., 
1914). 

The writer had several cases that 
showed a transient albuminuria after 
lavage of the stomach, although 
nothing of the sort was present be¬ 
fore. Schiff (Wiener klin. Woch., 
May 28, 1914). 

The writer examined the urine of 
every soldier admitted to the sur¬ 
gical hospital in his charge, a total of 
3210 men. Albumin was found in 13 
per cent, but never in large propor¬ 
tions. Engel (Deut. med. Woch., 
Nov. 23, 1916). 

PHYSIOLOGICAL CYCLICAL, 
ORTHOSTATIC, AND ORTHOTIC 
ALBUMINURIA. —The question of 
physiological albuminuria in adults 
has been much discussed during the 
past few years and has particularly 
engaged the interest of the medical 
men employed in insurance work. 

Stirling was the first to call atten¬ 
tion to intermittent albuminuria in 
children in connection with the posi¬ 
tion of the body, and he styled it 
“postural albuminuria” The writer 
holds that this is the best name for 


it, as neither the orthostatic nor the 
lordotic attitude ever induce it except 
in the predisposed. Of the 204 chil¬ 
dren examined, albuminuria could be 
induced by lordosis alone in only 3 
per cent., and by a change from the 
seated to the erect posture (orthos- 
tatism) only in 1.3 per cent. Both 
together, the children not keeping 
still, induced albuminuria only in 1.6 
per cent. The findings in the vari¬ 
ous groups listed show that the rest¬ 
lessness of children responds to a 
physiologic demand, and that chil¬ 
dren should not be expected to sit 
still in school. The school desk 
should be arranged. Jeanneret (Arch 
de Med. des Enfants, Sept., 1915). 

A study of 5 cases of orthostatic 
albuminuria led to the conclusion 
that it is a general systemic disturb¬ 
ance, manifesting itself in faulty de¬ 
velopment, as shown by a general 
visceroptosis, a “drop heart,” a gen¬ 
eralized muscular and visceral atonia, 
which is known to be associated with 
varying degrees of vasomotor in¬ 
stability. The symptoms so com¬ 
monly complained of, such as head¬ 
ache, lassitude, constipation and loss 
of weight, are the natural results of 
physical conditions. The increased 
lordosis that is usually present is re¬ 
garded as a symptom due to the 
faulty muscular development and 
tone of the lumbar muscles. The 
low pulse-pressure is undoubtedly the 
cause of the albuminuria rather than 
a mechanical interference with the 
venous return from the kidneys. 
Mason and Erickson (Amer. Jour. 
Med. Sci., Nov., 1918). 

It is characteristic of physiological 
albuminuria that the quantity of albu¬ 
min is generally small and that the 
excretion is, in most cases, intermit¬ 
tent, or cyclical. Leube, Pavy, Fiir- 
bringer, Klemperer, and many other 
authors have studied this condition. 

Pavy introduced the denomination 
‘‘cyclical albuminuria” for the cases 
in which the albuminuria ceases and 
returns at regular intervals. 


468 


ALBUMINURIA (LEVISON AND ERLANDSEN). 


Stirling ascribes cyclical albumi¬ 
nuria to a sudden shock from the 
blood-pressure upon assuming the 
upright position on arising, but 
Rudolph showed that albumin also 
appeared in the urine when the up¬ 
right position was assumed very 
slowly. 

Pavy likewise insists upon posture as 
the invariable cause of cyclical, or in¬ 
termittent, albuminuria, the excretion 
ceasing when the subject is in the re¬ 
cumbent position and going on only 
when he is walking or standing. The 
cycles are commonly completed within 
the day, but in a case narrated by Klem¬ 
perer there were two cycles, the maxi¬ 
mum of albuminuria taking place in the 
forenoon and afternoon. 

Hauser concludes that these cases 
can always be traced back to an uncured 
nephritis or to some acute infection 
(notably scarlatina), and puts no cre¬ 
dence in a functional disorder. In other 
words, he always considers cyclical aP 
buminuria as the expression of some 
pathological factor. 

Oswald attributes all forms of albu¬ 
minuria of adolescence to irritation of 
the renal epithelium. 

Moritz ascribes cyclical albuminuria 
to some insufficiency of the circulatory 
apparatus, having observed that the in¬ 
creased blood-pressure which normally 
occurs after moderate exercise is fol¬ 
lowed by abnormally low pressure in 
individuals that are subject to cyclical 
albuminuria. 

The diagnosis of physiological albu¬ 
minuria ought not to be made except in 
cases when persons presenting no other 
symptoms of disease excrete, constantly 
or intermittently, a urine containing a 
scanty quantity of albumin, but no 
morphotic elements and especially no 
casts. The centrifugal apparatus, now 


in general use, will certainly contribute 
to restrain the number of these cases. 
The urine should be obtained by 
catheterism in all doubtful cases. 

The prognosis is generally considered 
good (Broadbent, Beck, Dukes, Ties- 
sier, Posner). Nevertheless it is still 
justifiable for life-insurance examiners 
to be cautious in accepting persons 
suffering from albuminuria. 

It is no longer justifiable for life in¬ 
surance and other such examiners 
to take the serious view hitherto ac¬ 
cepted by most clinicians of physio¬ 
logical albuminuria. When it is 
found that the excretory function is 
being properly performed; that the 
substances normally gotten rid of 
through the kidneys are not being re¬ 
tained in the organism, and that the 
albumin in the urine may be dimin¬ 
ished by lessening the hydrostatic 
pressure upon the renal capillaries by 
increasing the coagulability of the 
blood, there is every reason to con¬ 
clude that the kidneys are free from 
organic disease, that life is not in the 
least endangered. Instances reported 
in which excellent results have been 
achieved by the administration of cal¬ 
cium chloride in doses of 20 grains 
three times a day. Calcium lactate in 
the same dosage is also useful. Both 
increase the coagulability of the 
blood. A. E. Wright and G. W. Ross 
(Lancet, Oct. 21, 1905). 

Very small proportions of albumin 
should not be taken into account in 
relation to life insurance, and conse¬ 
quently the writer does not regard 
as of much moment the efforts to 
produce more and more delicate tests 
for albuminuria. The so-called phys¬ 
iological slight albuminuria after ex¬ 
cessive exertion, sports, etc., may also 
be disregarded. The majority of 
cases of orthostatic albuminuria are 
also comparatively harmless; it is ex¬ 
ceptional for nephritis to develop 
later in these cases. In examining it 
is important to note the absence of 
the higher blood-pressure character¬ 
istic of contracted kidney; also that 


ALBUMINURIA (LEVISON AND ERLANDSEN). 


469 


the urine is free from albumin during 
reclining. Fiirbringer (Deut. med. 
Woch., Nov. 25, 1909). 

Teissier distinguishes three groups of 
orthostatic albuminuria: The true or¬ 
thostatic albuminuria, where the albu¬ 
min appears very soon after assuming 
the erect posture. It disappears in the 
recumbent posture. The mixed ortho¬ 
static albuminuria, which, more slow in 
its development (usually not before ten 
and twelve in the morning), is found 
in persons with an earlier acute infec¬ 
tion and believed to be due to actual 
organic changes in the kidney. The 
associated orthostatic albuminuria is 
also slower in making its appearance 
after assuming the erect posture and is 
associated with abnormal conditions of 
other organs (dilated stomach, ente- 
roptosis, movable kidney, etc.). 

Orthostatic albuminuria was noted 
by the writer in 14.9 per cent, of 1076 
school children in Christiana. It was 
much commoner among the girls 
than among the boys, the figures be¬ 
ing 13.3 per cent, and 3.5 per cent,, 
respectively. Bugge (Norsk. Mag. f. 
Laegevid., Ixxiv, No. 12, 1913). 

In a study of orthostatic albumin¬ 
uria among 189 healthy English 
school boys, the writer found that 7.5 
per cent, showed albumin on arising, 
7 per cent, after breakfast, 10.7 per 
cent, after football, and 18 per cent, 
after a three-mile run. Nicholson 
(Pract., xciii, p. 113, 1914). 

Analysis of 14 cases of orthostatic 
albuminuria, 9 being children at 
about puberty, 4 young men and 1 
woman of 33. The writer concludes 
that it requires no special treatment, 
but differentiation is extremely im¬ 
portant as otherwise unnecessary re¬ 
strictions and other measures are 
imposed for the assumed underlying 
nephritis. This is particularly disas¬ 
trous in these cases because persons 
with orthostatic albuminuria are usu¬ 
ally frail and may be predisposed to 
tuberculosis; there is also a tendency 


to oxaluria. The orthostatic albumin¬ 
uria disappeared completely or be¬ 
came much attenuated when the 
oxaluria was arrested by giving a 
level teaspoonful of calcined mag¬ 
nesia two or three times a day. With 
nephritis, the albumin content of the 
urine shows little change day or 
night. Scheel (Ugesk. f. Laeger, 
Mar. 7, 1918). 

The writer conducted an examina¬ 
tion of the urine of 401 boys and 311 
girls in the school before and after 
the gymnastics class and, when al¬ 
buminuria was found, the child was 
ordered to bring morning urine for 
examination. The children were all 
of the upper grades in the school. 
Albuminuria before the gymnastics 
was evident in 8 per cent, of the boys 
and 24 per cent, of the girls; after 
gymnastics, in 14 per cent, of the 
boys and 33 per cent, of the girls. In 
both categories the percentages grew 
higher the older the children; among 
the girls of the sixth grade and higher 
grades the proportion was 49 per 
cent. Fully 90 per cent, were frail 
children among those with lordotic 
albuminuria, and 70 per cent, of those 
with albuminuria in general; only 10 
per cent, of the total were lively 
healthy children. Hamelberg (Nederl. 
Tijdsch. V. Geneesk., Mar. 9, 1918). 

Even when no casts can be found, 
albuminuria ought never be regarded 
as absolutely inoffensive. Although a 
cyclical albuminuria continuing years 
may be compatible with perfect health, 
many authors (Johnson, Greenfield, 
Bull, etc.) are of the opinion that it sig¬ 
nifies the first stage of the evolution of 
granular atrophy of the kidneys. On 
the other hand, casts may be found in 
normal urine and do not mean nephritis. 
Tuttle, for example, believes that ne¬ 
phritis may exist without albuminuria. 

The writer examined post mortem 
the kidneys of a youth of 16 who had 
had typical orthostatic albuminuria 
during the last 5 or 6 years, but who 
had been otherwise in normal health 


470 


ALBUMINURIA (LEVISON AND ERLANDSEN). 


until he contracted “galloping tuber¬ 
culosis” of the lungs. Not a trace of 
inflammation could be discovered in 
the kidneys. He reports also 10 
clinical cases in which orthostatic al¬ 
buminuria was a chronic condition, 
but in which no tubular casts were 
ever found. On the whole, while al¬ 
buminuria may coincide with tuber¬ 
culosis, orthostatic albuminuria can¬ 
not be deemed an indication of this 
condition. Holst (Norsk. Mag. f. 
Laegevid., Nov., 1915). 

The albuminuria often found in par¬ 
turient women (Aufrecht saw it in 56 
per cent, of all cases) must be regarded 
as physiological. 

Albuminuria occurring during labor 
is a reasonable accompaniment of 
parturition; the quantity is greater 
than can be considered normal, and 
is often the greatest seen in any ex¬ 
cept a permanent pathological condi¬ 
tion. The condition requires no 
especial and separate treatment, and 
cannot be considered a permanent 
pathological lesion. The albumin¬ 
uria of labor is differentiated from 
the other by the presence of labor 
and by the fact that it ceases 
after parturition. The more abundant 
the albumin, the more gradual is its dis¬ 
appearance. The albuminuria of the 
puerperal period is the continuation of 
that of labor, and is never a separate 
condition. The albuminuria of labor is 
most pronounced toward the end of 
parturition, especially in cases of diffi¬ 
cult or complicated labor. Circum¬ 
stances which do not tend to make par¬ 
turition especially difficult have no in¬ 
fluence upon its albuminuria. The sedi¬ 
ment of urine taken during labor shows 
organized material, including cylin- 
droids, so often seen in cases of abun¬ 
dant albuminuria. These cylindroids 
are not abundant, and are to be dis¬ 
tinguished from others by the fact that 
they contain superficial kidney epithe¬ 
lium in abundance, but not the elements 
which come from the deeper kidney 
structures. Jageroos (Archiv f. Gyn., 
Bd. xci, Hft. 1, 1910; Amer. Jour. Med. 
Sci., Nov., 1910). 


In an exhaustive study of several 
patients the writers noted that the 
condition appeared in the strong and 
well-developed as well as in the weak 
and anemic types. They are inclined 
to believe that the explanation is to 
be found in a mechanical cause, re¬ 
sulting in congestion of the renal 
vessels, together with a local and 
general predisposition. Supporting 
apparatus by improving the posture, 
gave good results. Fischl and Pop¬ 
per (Boston Med. and Surg. Jour., 
May 4, 1916). 

PATHOLOGICAL ALBUMINU¬ 
RIA. — Pathological albuminuria is 
found in pathological changes of the 
blood—as anemia, leukemia, pseudo- 
leukemia, scurvy, icterus, and diabetes 
—even when the kidneys do not present 
pathological changes. 

It is also found in many disorders 
of the nervous system, as epilepsy, 
migraine, psychosis apoplexy, neuras¬ 
thenia, and Basedow’s disease, etc. 
Delirium tremens has also been men¬ 
tioned as a nervous disease often com¬ 
plicated with albuminuria. H. H. 
Schroeder regards excessive eating, 
overindulgence in alcoholic drinks and 
possibly tobacco as the most frequent 
causes of albuminuria. 

Although the kidneys are theoretically 
believed to be healthy in the diseases 
mentioned above, there is no doubt that 
albuminuria, in many cases of this class, 
is caused by pathological changes of the 
kidneys. 

In all febrile and' especially in all in¬ 
fectious diseases albuminuria is a very 
frequent symptom. It has been noticed 
in enteric fever, diphtheria, variola, 
after vaccination, in erysipelas, influ¬ 
enza, rheumatic fever, pneumonia, etc. 
In these cases the albuminuria is caused 
by changes in the composition of the 
blood, increase of blood-pressure, rise 
of temperature, and finally by changes 


ALBUMINURIA (LEVISON AND ERLANDSEN). 


471 


in the structure of the kidneys, espe¬ 
cially of the tubular epithelial cells 
caused by the toxic substances excreted. 

The presence of albuminuria in 
preg-nancy, as stated above, is com¬ 
mon (56 per cent.). Casts are only 
found in about 50 per cent, of these 
cases of simple albuminuria. The so- 
called kidney of pregnancy is to be 
regarded as a specific toxic nephritis 
which tends to recur in subsequent 
pregnancies. The prognosis of it, i£ 
properly treated, is good. 

Albuminuria has been observed in 
diseases of the intestines, dilatation of 
the stomach, ileus, ruptures, etc., and 
in renal venous congestion caused 
commonly by disease of the heart or 
the great vessels. 

It is present in all diseases of 
the kidneys. Acute, as well as 
chronic, albuminuria' is generally 
found in the diffuse forms of nephri¬ 
tis, as well as in circumscribed renal 
diseases—such as infarcts, abscesses, 
or tumors. After retention of urine 
the portion of urine first passed is 
frequently albuminous. 

Albumin is found in many diseases 
of the ureter, the bladder, the pros¬ 
tate and urethra. Ballinger speaks 
of prostatic albuminuria as a name 
for an albuminous secretion from 
an hyperemic or inflamed prostate. 
This prostatorrhea is constant in 
chronic prostatitis and often increases 
regularly every ten to thirty days. 
It should not be taken for a true al¬ 
buminuria. 

The writer recognizes the existence 
of a distinct and well-characterized 
form of albuminuria of rather favor¬ 
able prognosis that is not due to a 
nephritis of toxic or infectious origin, 
to circulatory disturbances in the kid¬ 
neys, nor to general cardiorenal dis¬ 
ease, but to perversion of the gastro¬ 


intestinal and hepatic ductions. Crof- 
tan (Arch, of Diagnosis, Oct., 1908). 

After a study of 62 cases the writer 
challenges the prevailing view that 
while the diseased kidney may not 
permit urea, salt or even water to 
pass, it will allow the big albumin 
molecule to filter through. His study 
and experiments showed that inflamed 
kidney epithelium does not allow the 
passage of serum albumin, and that 
the albumin found in the urine does 
not come from the blood but must 
be secreted by the renal epithelium 
itself, an active, vital function. All 
the tests showed that filtering ascites 
fluid, pleural effusions, blood serum 
and similar fluids through a delicate 
animal membrane, such as the rabbit 
and cat intestine, the albumin content 
of the filtrate was about the same as 
that of the original fluid, and the pro¬ 
portion of albumin to globulin per¬ 
sisted unmodified, but when the mem¬ 
brane was hardened or otherwise ren¬ 
dered less permeable, the globulin was 
arrested first; with increasing imper¬ 
meability none of the albumin passed 
into the filtrate or dialysate. Apply¬ 
ing these findings to conditions in 
the kidney, either the proportion of 
globulin and albumin should be the 
same in the urine as in the blood, or 
the albumin should predominate. But 
this is not the case with diseased kid¬ 
neys. A relative excess of globulin 
was found in the urine in simply con¬ 
gested kidneys and in orthostatic 
albuminuria. Mandelbaum (Deut. 
Archiv f. klin. Med., Oct. 24, 1920). 

Merk found that many afifections 
of the skin, eczema, pruritus, urti¬ 
caria, erythema, and furunculosis, are 
intimately associated with albumi¬ 
nuria. Gunsberger noted albumi¬ 
nuria during a severe attack of acute 
urticaria. Nicolas and Jambon and 
Boas hold that albuminuria is a fre¬ 
quent accompaniment of scabies, but 
it is not satsfactorily settled how it 
produces this phenomenon. 

Lancereaux observed frequently al- 


ALBUMINURIA (LEVISON AND ERLANDSEN). 


472 

buminuria in his cases of gouty, her¬ 
petic diabetes, but never noted it in 
his 40 cases of pancreatic diabetes. 
Glycosuria alone does not entail al¬ 
buminuria. When it occurs it may 
be connected with arteriosclerosis, 
with subsequent lesions of the kid¬ 
neys and heart, or be due to some 
intercurrent afifection, tuberculosis in 
particular. 

Certain remedies may also give rise 
to albuminuria. 

The prognosis and treatment of 
albuminuria, therefore, depend en¬ 
tirely on the origin and causes of it, 
and the reader is referred to the 
various diseases in which it occurs as 
a symptom. 

Investigations showing the existence 
in many cases of a direct relationship 
between the acid content of the urine 
and the amount of albumin and tube 
casts present. In the first case of al¬ 
buminuria, the administration of phos¬ 
phoric acid was found to cause an im¬ 
mediate increase in the albuminuria. 
In other words, with an increased 
acidity of the urine, there was a corre¬ 
sponding increase in the amount of al¬ 
bumin. On the administration, how¬ 
ever, of alkalies in place of the acid, 
the albumin and tube casts diminished 
and finally disappeared. All the cases 
which were examined showed that, with 
increased acidi^^y, there was increased 
albuminuria, and, corresponding with a 
diminution in acid, there is a diminution 
in the albuminuria.. At the same time, 
in all cases of advanced grave kidney 
trouble, and especially in uremic pa¬ 
tients, the relationship to acidity cannot 
always be demonstrated. The writer 
goes on to show that not only is the 
albuminuria lessened by alkali adminis¬ 
tration, but the functioning of the kid¬ 
ney is greatly improved and the very 
important excretion of chlorides is ac¬ 
celerated. The best mode of adminis- , 
tration of the alkali is in the form of 
the ordinary sod. bicarb., which must 
sometimes be given in large doses. V. 


Hoesslin (Miinch. med. Woch., Aug. 
17, 1909). 

Albuminuria is most constant after 
operations on the abdominal, genital 
and urinary organs. In case of pre¬ 
existing kidney lesions rapid operat¬ 
ing is necessary. The general anes¬ 
thesia kept up for an hour or longer 
might prove fatal just as well with^ 
out any operation, other things being 
equal. The writer observed albumin¬ 
uria after accidental traumatism, 
showing that the shock is the 
main factor rather than the anes¬ 
thetic in postoperative albuminuria. 
Satre (Paris med.. May 26, 1917). 

The writer calls attention to a 
form of chronic nephritis with albu¬ 
minuria which is often insidious and 
found in apparently healthy persons 
in the course of routine examinations. 
The same afifection has also been 
classed among the cyclic or orthos¬ 
tatic albuminurias of adolescents. 
The features are those of a non-pro¬ 
gressive nephritis with small amounts 
of albumin, occasional granular and 
hyaline casts, and a normal phenol- 
sulphonephthalein excretion. Such 
cases usually show no obvious cause 
of the nephritis and albuminuria, but 
on careful examination there will be 
found to be some chronic focus of in¬ 
fection, such as the tonsils, kidney 
stone, etc., removal of which leads in 
a few months to complete recovery 
of normal kidney function with free¬ 
dom from albumin and casts in the 
urine. 

Several illustrative cases are given 
by the writer. In one of these the 
infection was bronchial and the 
staphylococcus was isolated from the 
sputum. The administration of a 
vaccine cured both the infection and 
the nephritis. Dental abscesses are 
also very frequent foci of infection 
which lead to these forms of neph¬ 
ritis. While recovery follows the re¬ 
moval of all foci of chronic infection, 
its progress may cover several 
months, during which the irritation 
of the kidneys is being gradually re¬ 
paired. David Riesman (Jour. Amer. 
Med. Assoc., Dec. 15, 1917). 


ALBUMINURIA (LEVISON AND ERLANDSEN). 


473 


TESTS.—By means of the tests 
commonly employed the presence of 
albumin in the urine is revealed, but 
no attempt is made to discern be¬ 
tween the different proteids; the dif¬ 
ferential diagnosis between the serum- 
albumin, globulin, etc., will be given 
later on. 

The sample of urine to be examined 
must be very limpid without deposits 
of any kind; if this be not the case, 
the urine should be filtered previous 
to the examination, because a slight 
cloud of coagulated albumin will only 
be discernible when the fluid is very 
clear before the reagent has been 
added. When the urine contains 
many bacteria, even repeated filtra¬ 
tion will be insufficient to make it 
clear; this can then be done, however, 
by addition of a solution of sulphate 
of magnesia and of carbonate of soda. 
By shaking the mixture a precipitate 
of carbonate of magnesia is formed, 
and when this is removed by filtra¬ 
tion the filtrate will be perfectly 
clear. In many cases a few drops of 
caustic soda will clear the urine, but 
urine treated in this manner will not 
give a precipitate of albumin by boil¬ 
ing, while the test of Heller is practi¬ 
cable also in this case. 

Test by Boiling.—A few c.c. of 
urine are heated to the boiling point 
and some (5 to 10) drops of nitric 
acid added. When the urine is acid 
the albumin will ordinarily coagulate 
by boiling alone and precipitate as 
a whitish powder or in small flakes. 
The nitric acid is nevertheless in all 
cases to be added, as well in order 
to complete the precipitation of albu¬ 
min as to avoid mistakes caused by 
the presence of a precipitate of phos¬ 
phates or carbonates,—which will 
immediately dissolve when nitric acid 


is added. This test is very delicate 
and will reveal 0.01 to 0.005 per 
cent, of albumin. Instead of nitric 
acid, acetic acid - can be employed, 
but, while the nitric acid is to be 
added after boiling and in a quan¬ 
tity of 5 to 10 drops, acetic acid is 
added before the boiling, and only a 
sufficient quantity (1 to 2 drops) 
should be employed as to make the 
urine but slightly acid. This is espe¬ 
cially necessary when the urine is 
alkaline, because the alkaline albumi¬ 
nates with a surplus of acetic acid 
give a compound which is not coagu¬ 
lated by boiling. 

Tretrop heats the urine nearly to a 
boiling point and adds a few drops of 
a 40 per cent, solution of formalin. 
The albumin coagulates like white of 
egg. After pouring off the fluid, the 
proportion of albumin can be deter¬ 
mined by weighing the coagulum left. 

Bychowski describes the following 
simple method to detect the presence 
of albumin, even if only a few drops 
of urine can be obtained: One or 2 
drops of urine are put in a test-tube 
of hot water. After shaking, a 
whitish cloud is formed, if albumin is 
present. The test is very distinctive 
and is still more apparent when the 
test-tube is held against a black back¬ 
ground. Of course, phosphates give 
the same reaction, but the cloud dis¬ 
appears on the addition of a drop of 
acetic acid. 

Test for albumin in the urine in 
which the extra work of having a con¬ 
trol or the filtering of the urine or the 
modification of its reaction has been 
eliminated. 

Material needed for the test: Satu¬ 
rated salt solution, acetic acid, test- 
tube, pipette. 

On heating urine three substances 
may be thrown down: albumin, nucleo- 


474 


ALBUMINURIA (LEVISON AND ERLANDSEN). 


proteid, and phosphates. About 5 to" 
10 c.c. of saturated salt solution, slightly 
acidulated with acetic acid, is heated to 
boiling in a test-tube. The urine to 
f be tested is carefully allowed to run 

on top of the hot salt solution by 
means of the pipette. In order to 
make a good picture, the quantity of 
urine used ought to equal that of the 
salt solution. 

By means of the heat in the sat¬ 
urated acidulated salt solution the 
above-mentioned substances are likely 
to be precipitated, but, owing to the 
contact, the saturated salt will not 
let the nucleoproteids appear, while 
the phosphates are also held in sus¬ 
pension by the acid; hence nothing can 
appear at the point of contact of the 
hot saturated salt with the urine except 
albumin. 

Depending on the quantity of albumin 
present the reaction will be marked or 
only a film will appear overlying the 
clear, crystal-like salt solution. It is in 
urine with a trace of albumin in 
which this test shows extreme delicacy. 
The clear, crystal-like salt solution and 
the control-column of urine above with 
the surface of contact contrast quite 
decisively in distinguishing a delicate 
cloud. 

Different pictures are produced in the 
great variety of urines by means of 
this technique:— 

1. In clear urine which contains no 
albumin the delicate point of contact 
where the urine rides the hot salt solu¬ 
tion is better brought out by setting 

; the solution in motion by gently shak¬ 
ing the tube to and fro. 

2. In clear urine sometimes a cloud 
appears some distance above the point 
of contact. This is due to the heat, 
which, traveling farther and faster than 
the acid of the salt solution, throws 
down a phosphate cloud. 

3. Cloudy urine due to phosphates or 
urates is cleared at the point of contact 
because the acid and the heat dissolve 
these, respectively. 

4. In cloudy urine due to bacteria no 
change is seen in the urine at the point 
of contact, and here, at times, only a 
close scrutiny of the urine above the 


crystal-like salt solution below in com¬ 
parison with the zone of contact will 
give us the correct reading. 

5. In urine containing albumin 
clouded by urates or phosphates, the 
albumin cloud at the contact differs in 
density from the remainder of the 
urine. Often the film of coagulated 
albumin is so delicate that the clearing 
of urates or phosphates is again seen 
above that of the contact zone. 

6. In albuminous urine clouded by 
bacteria the coagulated albumin at the 
point of contact accentuates its pres¬ 
ence by its difference in density. 

It is in cloudy urine that the control 
of a clear, crystal-like liquid below the 
urine above emphasizes the beauty of 
the reaction in the zone of contact. 

This test is a modification of the 
saturated salt, or brine, test, yet it adds 
to this old method the new qualities of 
diminished labor, simplicity, and ac¬ 
curacy. H. L. Ulrich (Jour. Minn. 
State Med. Assoc., Feb. 15, 1909). 

Method of employing the acetic 
acid test for the detection of albumin 
which has long been used in France: 
20 c.c. of urine, about three-fourths 
of a test-tube 1.5 cm. in diameter, are 
treated with 5 drops of 20 per cent, 
acetic acid, mixed, and one-half 
poured into a second test-tube. The 
contents of one tube are boiled, the 
other serving as a control. Albumin 
produces a cloud or precipitate in the 
boiled tube. Before testing, the 
urine must, of course, be perfectly 
clear; if necessary, it is shaken with 
Kieselguhr and filtered. If the acetic 
acid causes a cloud in the cold 
(nucleoalbumin), it is cleared by 
filtration before boiling. An alkaline 
urine should be acidulated slightly to 
prevent the precipitation of the phos¬ 
phates, or, if a precipitate of phos¬ 
phates appears when the urine has 
been treated with acetic acid and 
boiled, a few more drops of the dilute 
(20 per cent.) acid may be added to 
dissolve it. This will not redissolve 
even a slight albuminous cloud, pro¬ 
vided the urine is not boiled again. 
Glaesgen (Miinch. med. Woch., Bd. 
Iviii, S. 1123, 1911). 


ALBUMINURIA (LEVISON AND ERLANDSEN). 4/5 


Heller’s Test.—Three to 4 c.c. of 
nitric acid are poured in a test-tube 
and a few c.c. of urine are cautiously 
filtered down along the sides of tlie 
tube without shaking the latter. The 
nitric acid rests on the bottom of the 
test-tube, and where the fluids are in 
contact a distinctly limited disk of 
grayish-white precipitate will appear. 
When only traces of albumin are pres¬ 
ent the precipitate will only take place 
after some minutes. The more or less 
distinct violet coloring which also ap¬ 
pears at the point of contact of the two 
fluids is due to oxidation of indican or 
other chromogens. This test is very 
delicate and reliable; 0.003 per cent, 
of albumin is revealed by it. 

Fallacies .—By the addition of nitric 
acid the urates or urea are also pre¬ 
cipitated; these will not form a 
limited disk, but render the urine 
turbid. Resinous acids (copaiba, 
etc.) are precipitated by nitric acid, 
but are dissolved by the addition of 
concentrated alcohol. This error can 
be avoided by diluting the urine or 
by moderately warming the nitric 
acid before the test. Very often also 
a fine disk or ring will appear above 
the point of contact. This ^precipita- 
tion is due (Morner) to the presence 
of nucleoalbumins (mucin, chondrolin, 
sulphuric acid, etc.) and is more dis¬ 
tinct after dilating the urine. 

Test by Acetic Acid and Potassic 
Ferrocyanide.—The urine is rendered 
acid by acetic acid, and some drops of 
a solution of potassic ferrocyanide are 
added. This reagent, the serum-albu¬ 
min, the globulin, and the albumoses are 
precipitated, while none of the normal 
constituents of the urine are (Huppert). 

Heynsius’s Test.—A still more deli¬ 
cate test than Heller’s is that of Heym 
sius, by acetic acid and sulphate of soda. 


The urine is rendered acid by acetic 
acid, and an equal volume of a saturated 
solution of sulphate of soda (or of 
common salt) is added. The mixture is 
boiled, and all kinds of albumin will 
then be precipitated in white flakes. 

The Magnesium-nitric Test (Rob¬ 
erts’s).—One c.c. of nitric acid is 
mixed with 5 c.c. of a saturated solu¬ 
tion of sulphate of magnesium, and a 
small quantity of this mixture is 
added to the urine. The albumin will 
be precipitated as a distinct ring. 

Metaphosphoric Acid (Hinden- 
lang’s) also precipitates albumin in 
the same manner as nitric acid; but this 
test is not as delicate as that of Heller. 
The solution of metaphosphoric acid 
must be freshly prepared for use, as the 
solution easily changes to orthophos- 
phoric acid upon standing, which does 
not precipitate albumin. 

Picric Acid Test (Johnson’s).—A 
few drops of a saturated solution of 
picric acid will cause a white precipitate 
when albumin is present; this test is 
only indicative of the presence of albu¬ 
min, however, when the precipitate 
appears immediately. The urine must 
be acid. After some time the uric acid 
and the creatinine will also be pre¬ 
cipitated (Jaffe). 

Fallacies .—By addition of picric acid 
and peptones, the resinous acids,—such 
as those of copaiba,—and alkaloids— 
such as morphine—are precipitated. 

Perchloride-of-mercury or Spiegler 
Test.—A solution of 8 grams of mer¬ 
cury, 4 grams of tartaric acid, 20 grams 
of glycerin in 200 grams of water pro¬ 
duces a precipitate of albumin. The 
test is carried out in the same manner 
as Heller’s test. It is very delicate (it 
reveals 0.0002 per cent, of albumin), 
but is not reliable when the urine is poor 
in chlorides (Jolles). 


476 


ALBUMINURIA (LEVISON AND ERLANDSEN). 


Millon’s Test.—A solution of nitrate 
of mercury is added to the urine and 
the mixture heated to boiling. Nitrate 
of potash is then added; the albumin 
presents as a precipitate of red flakes. 
This test is disturbed by the sodium 
chloride of the urine and will be much 
better if tried upon the precipitate after 
boiling the urine. 

Tanret’s Test.—The reagent of Tan- 
ret is composed of perchloride of mer¬ 
cury, 135 grams; iodide of potash, 3.32 
grams; glacial acetic acid, 20 c.c; dis¬ 
tilled water, sufficient to make 100 c.c. 

Some drops of this mixture are added 
to the urine, when it will coagulate the 
albumin. It will also, however, pre¬ 
cipitate the urates. 

Tognetti described a ‘Tannohydro- 
chloric” test which reveals albumin, 
even in a proportion of 1 to 2,000,000. 
An equal amount of 1.5 per cent, alco¬ 
holic solution of tannin is added to the 
urine. After heating, an equal amount 
of 33 per cent, hydrochloric acid is 
added. A yellowish-white precipitate 
is gradually thrown down. 

Colquhoun recommends a solution of 
carbolic acid in absolute alcohol; this 
gives a white, milky precipitation of 
albumin. The test is said to show 0.002 
per cent, albumin. 

Many other reagents have been 
recommended, which cannot be men¬ 
tioned in detail. The boiling test, Hel¬ 
ler’s test, the potassic ferrocyanide test, 
and the picric acid test are the most 
practicable and quite sufficient in gen¬ 
eral work. 

After illustrating the disadvantages 
of various procedures hitherto widely 
recommended, the writer advocates, 
after extensive clinical experience, a 
diaphanometric method. In prepar¬ 
ing the necessary standard solution, the 
albumin content of a given albumin¬ 
ous urine is first accurately measured 


by the weighing method. Some of 
the urine, previously filtered, is then 
diluted with a solution consisting of 
sodium chloride, 7.5 grams, and mer¬ 
cury cyanide, 1 gram, in distilled 
water, enough to make 1 liter, until 
it contains 1 gram of albumin per 
liter. In successive test tubes of 
equal diameter are now placed re¬ 
spectively, 0.5, 0.7, 0.8, 0.9, 1.0, 1.2, 
1.4, 1.6, 1.8, and 2 mils of the result¬ 
ing mixture, and the fluid in each 
tube made up to 10 mils with the 
chloride cyanide solution. The vari¬ 
ous tubes thus correspond to samples 
of urine containing from 0.05 to 0.8 
gram of albumin per liter. To each 
tube is added 2 mils of a 20 per cent, 
solution of trichloracetic acid. A tur¬ 
bidity of increasing intensity in the 
successive tubes is thus produced. 
After being shaken, the tubes ate 
carefully stoppered or sealed and 
labelled. File marks at 10 and 12 
mils are now made on an additional 
tube of the same diameter as the 
standard series. In testing urine, a 
test for gross albumin content is first 
made by the qualitative method and 
the urine, if necessary, diluted with 
saline solution so as to contain from 
0.05 to 0.2 gram of albumin per liter. 
The urine is then placed in the 
empty tube up to the 10-mil mark, 
trichloracetic acid solution added up 
to 12 mils, and the mixture shaken. 
The standard tubes are now all 
shaken and the urine mixture under 
test compared with the standards 
until an equal degree of turbidity is 
found. Bauzil (Jour. Amer. Med. 
Assoc., from Paris med., Oct. 5, 1918). 

Xanthoprotein Test.—Albuminous 
urine heated with a surplus of con¬ 
centrated nitric acid will take a yellow 
color, and some of the albumin coagu¬ 
lates in yellow flakes, which are soluble 
in alkalies with an orange-red color. 

Very minute quantities of albumin 
may be detected in the urine by means 
of the deviation-of-complement test. 
For antigen the writer has used the 
serum of rabbits which had been im¬ 
munized against human blood-serum. 


ALBUMINURIA (LEVISON AND ERLANDSEN). 


When albuminous urines were diluted 
to such a point that they no longer 
gave a reaction with heat and acetic 
acid or with nitric acid, they still 
yielded positive results by the comple¬ 
ment-deviation test, while in many 
instances albumin could be detected by 
this method in diluted urine when it 
could not be demonstrated by the ordi¬ 
nary chemical tests. The deviating 
power of the urine is not affected either 
by filtration through a Berkefeld filter 
or by dialysis. The antibody of the 
urine was, moreover, found to reside 
entirely in the serum albumin and 
serum globulin, and after the removal 
of the substances from the urine the 
remaining fluid no longer had the 
property of an antibody. C. H. Wilson 
(Jour. Path, and Bact., vol. xiii, p. 
484, 1909). 

Following are two new qualitative 
tests for albumin in urine, which are 
apparently specific as well as simple. 
The first test is with tincture of iodine 
and sodium bisulphate: A few c.c. 
(5 to 6) of the urine—which must, of 
course, be clear—are placed in a test- 
tube and acidified with a few drops of 
dilute acetic acid. About % volume of 
tincture of iodine (10 per cent.) is now 
added, and the whole is well shaken. 
A dirty, dark-brown precipitate results. 
A saturated solution (watery) of 
sodium bisulphate is next added drop 
by drop, shaking constantly, until the 
brownish fluid is decolorized. If the 
urine contains albumin, one sees a 
permanent whitish cloud or flocculent 
precipitate. If no albumin is present, 
the fluid remains clear after the addi¬ 
tion of the sodium bisulphate, and 
shows only the original urinary color. 
With minimal quantities of albumin, 
the reaction becomes more evident on 
standing a few minutes. The second 
is with decolorized tincture of iodine: 
One decolorizes tincture of iodine with 
saturated watery solution of sodium 
bisulphate and filters. The filtrate is 
a clear, rather yellowish fluid, which 
keeps well. On standing for some time, 
small, yellow crystals may be precipi¬ 
tated, without injury to the reagent. 
The urine, as in the first test, is acidi- 


477 

fied with dilute acetic acid. About % 
volume of the reagent is added and the 
whole well shaken. If albumin is 
present, a cloud or a flocculent white 
precipitate forms. With traces of al¬ 
bumin the reaction may be delayed a 
few minutes. Normal urine never 
shows a cloud with these tests. Oguro 
(Zeit. f. exper. Path. u. Therap., Bd. 
vii, S. 349, 1909; Amer. Jour. Med. 
Sci., Jan., 1910). 

In certain cases of profound gen¬ 
eral intoxication, such as cerebral 
hemorrhage cases in coma, uremia, 
and eclampsia, addition of 1 drop of 
urine to dilute, almost boiling Feh- 
ling’s produces a deep purple color. 
Blood serum gives the same reaction 
as do other proteins that are break¬ 
ing down to proteoses and peptones, 
i.e., substances giving the pink biuret 
test. Nine out of 10 cases seen which 
gave the test, died. H. Bieler (Jour. 
Labor. Clin. Med., v, 459, 1920). 

Transportable Reagents for Albu¬ 
min.—Hoffmann and Aazette employ 
strips of test-paper previously placed in 
a solution of the double iodide of potas¬ 
sium and mercury until saturated, then 
removed and dried. Geissler’s albumin- 
test paper is previously placed in a solu¬ 
tion of citric acid. The urine which is 
to be tested should be clear and ren¬ 
dered acid by means of a few drops of 
acetic acid. If there be albumin pres¬ 
ent, upon immersion of a slip of paper 
in the urine a distinct precipitate will 
appear. 

Pavy recommends test-pellets con¬ 
taining ferrocyanide of soda and picric 
acid; when albuminous urine is well 
shaken with a parcel of the pellet, albu¬ 
min will be precipitated. Stiitz and 
Fiirbringer employ capsuloids of gela¬ 
tin filled with perchloride of mer¬ 
cury, sodium chloride, and citric acid. 
The relative delicacy of the tests most 
frequently employed is graphically rep¬ 
resented by Unger-Vetlesen, in the 


478 


ALBUMINURIA (LEVISON AND ERLANDSEN). 


diagram shown below. The longest 
columns indicate the most delicate tests. 

Quantitative Tests. — The only 
method which gives fully reliable re¬ 
sults is the gravimetric method. One 
hundred c.c. of urine are boiled upon 
a water-bath half an hour; if precipi¬ 
tation does not take place a few drops 
of a weak solution of acetic acid are 
added; the liquid is now brought on 
a weighed filter and the precipitate 


Esbach employs an albuminimeter, 
i.e., a graduated glass tube; this 
tube is filled to one mark (U) with 
the urine and then to the mark R 
with the test-solution consisting of 
picric acid, 10 grams; citric acid, 20 
grams; water, 1 liter. The tube is 
then closed with a rubber stopper and 
the contents cautiously mixed (not 
shaken). The mixture is allowed to 
stand undisturbed for twenty-four 


Ferrocyanide of potassium and 
acetic acid. 

Solution of picric acid.. 

Test-paper. 

Solution of sulphate of soda and 
acetic acid. 

Heller’s test . 

Picric acid in crystals. 

Magnesium-nitric test (Roberts). 

Trichloracetic acid. 

Metaphosphoric acid . 

Boiling and nitric acid. 





B 
















i 




p 






% 

i 









;r rr 


" 





1 



1 










''m 


W§ 

i 








7-^ 

T;: 



i 








. 

I 





■ 










repeatedly washed with hot water. 
The filtrate must once more be acidu¬ 
lated with acetic acid and boiled 
again, in order to ascertain whether 
the precipitation has been quantita¬ 
tive. When the water has been 
removed from the filter by strong 
alcohol, and the alcohol with pure 
ether, the filter is dried at a tempera¬ 
ture of 110° to 120° C., and the per¬ 
centage of albumin determined by 
weighing. 

For clinical use several approxi¬ 
mate methods have been invented. 


hours and the quantity of precipitated 
albumin then read ofif. The reading 
indicates in grams the amount of 
albumin per liter. The urine must 
be acid, the specific weight should 
not be more than 1006 to 1008, and 
the temperature of the room approxi¬ 
mately constant (15° C.). Resinous 
acids must be extracted with ether. 
The yellow crystals often found on 
the side of the glass are crystals of 
uric acid. 

Christensen recommends another 
method: the albumin contained in 5 









































ALBUMINURIA (LEVISON AND ERLANDSEN). 


479 


c.c. of urine is precipitated by 10 
c.c. of a watery solution of tannic 
acid (1 per cent.). The albumin 
having been precipitated, 1 c.c. of 
an ordinary gum-arabic mucilage is 
added, the volume brought up to 50 
c.c. with water, and the whole con¬ 
verted to an emulsion by agitation. 
Upon a piece of white paper, ruled 
with black lines 0.5 mm. wide and 
at equal intervals, is placed a cylin¬ 
drical glass measuring 4 cm. in 
diameter. This is half-filled with 
water, and as much of the emulsion 
run in as possible without obscuring 
the black and white lines beneath the 
vessel. From the number of cubic 
centimeters required, reference to a 
table of calculations arranged by 
Christensen furnishes the proportion 
of albumin present in the emulsion. 
When the urine is alkaline it should 
be faintly acidified with acetic acid 
before the precipitation of albumin. 
This test can be made as well by 
daylight as by the light of a good 
lamp, and requires only ten or fifteen 
minutes; but is not applicable to 
urine containing a small amount of 
albumin, the variations amounting to 
two-thousandths. 

The polariscope is sometimes em¬ 
ployed to estimate the quantity of 
albumin, but this test is not reliable. 
It is true that albumin is levorota- 
tory, but this is also the case with 
normal urine, and sometimes the 
color of the urine is too dark to allow 
the use of the polariscope. 

Goodman and Stern have pointed 
out (1908) a quantitative method 
which gives results in a few minutes. 
It is based on the precipitation of 
albumin by phosphotungstic acid in 
the presence of a mineral acid. One 
gram of crystallized egg-albumin is 


dissolved in 100 c.c. of distilled water 
(solution A) ; 1 c.c. of this solution 
is diluted with 9 c.c. of distilled water 
(solution B). Drop in a test-tube 5 
c.c. of the following solution:— 


Phosphotungstic acid . 1.5 Gm. 

Hydrochl. acid (cone.) ... 5 c.c. 


Alcohol (95 per cent.). .q. s. ad 100 c.c. 

Now it takes 0.1 cm. (added with 
a pipette graduated in 0.1 c.c.) of 
solution B to cause a cloudy pre¬ 
cipitate, i.e., 0.0001 Gm. of albumin. 
The diluted urine is tested in the 
same manner. 

For the quantitative determination 
of albumin in the urine a simple test 
is recommended by the writer. He 
uses a round albuminometer. In this 
he places the urine and the Esbach, 
reagent and adds thereto 0.1 to 0.2 
Gm. of barium sulphate (tungspat); 
after mixing, the glass is set aside for 
precipitation. In 4 minutes it is 
complete. A urine containing over 2 
per thousand albumin should be 
diluted before using the test. Ander¬ 
son (Ugeskrift for Laeger, Apr. 26, 
1917). 

By the various tests above mentioned, 
qualitative as well as quantitative, the 
different coagulable proteids contained 
in the urine are precipitated; it is rarely 
of any use to differentiate them one 
from another. 

Globulinuria. — Pure globulinuria 
without the simultaneous presence of 
serum-albumin does not occur. In 
order to precipitate the globulin alone 
the urine is rendered alkaline with solu¬ 
tion of ammonia, after some time 
filtered, and the filtrate mixed with 
an equal volume of a saturated solu¬ 
tion of sulphate of ammonia. If glob¬ 
ulin be present a flaky precipitate will 
appear. 

[The same result can be obtained by using 
a solution of sulphate of magnesia, which 
does not precipitate the other proteids of 
urine, or by diluting the urine until it reaches 




480 


ALBUMINURIA (LEVISON AND ERLANDSEN). 


a specific gravity of 1002 and leading a slow 
current of carbonic acid through it for two 
or four hours. After twenty-four to twenty- 
eight hours the globulin will be precipitated. 
Levison.] 

Colorimetric Type. — Autenrieth and 
Mink (Miinch. med. Woch., Oct. 19, 1915) 
comparing the quantitative findings by 
colorimetry with other techniques obtained 
further confirmation of the precision of 
the colorimeter technique. 

[A colorimetric method of quantitative 
albumin estimation suitable for the prac¬ 
titioner’s use is described by W. Auten¬ 
rieth and F. Mink (Miinch. med. Woch., 
Oct.^ 19, 1915) as follows: Ten c.c. of 
clear or filtered urine in a test tube are 
heated for a few minutes on the boiling 
water bath. If a precipitate forms, 2 to 4 
drops of dilute acetic acid are added and 
the tube put back in the water bath. 
Usually at once, but sometimes only after 
a few minutes, the albumin all comes 
down in large flocculi. If the formation of 
the fiocculi is difficult because of the urine 
being poor in salts, 2 to 5 c.c. of saturated 
sodium chloride solution should be added. 
The precipitate is then at once placed on 
moistened filter paper and washed with 
about 20 c.c. of hot water, the latter hav¬ 
ing first been used to rinse out the test 
tube. The precipitate is next placed in a 
small funnel over a 10 c.c. graduate. Two 
to 3 c.c. of 3 per cent, souium hydroxide 
solution are placed in the test tube to dis¬ 
solve the remaining traces of albumin, and 
then over the precipitate itself, most of 
which easily goes into solution. Addi¬ 
tional 2 to 3 c.c. portions of the alkali are 
now used, until the albumin is completely 
dissolved and the total amount of solution 
is about 9.5 c.c. Four or 5 drops of 20 
per cent, copper sulphate solution are now 
added, the graduate filled to the 10-c.c. 
mark with alkaline solution, and the mix¬ 
ture well shaken up for two or three 
minutes. After allowing it to stand five 
or ten minutes, a clear supernatant fluid 
suitable for colorimetric examination will 
usually be found; if not, the mixture may 
be filtered through dry filter paper, the 
first few drops being discarded. The solu¬ 
tion having been placed in the glass 
trough of the Autenrieth-Koenigsberger 
colorimeter, comparison is made 5 or 6 


times with the wedge-shaped color scale 
of the instrument until 2 or 3 readings 
correspond. The final reading is then re¬ 
ferred to a curve chart, which shows the 
number of milligrams of albumin in the 
10 c.c. of urine. The method is held to be 
very accurate. Where the urine is be¬ 
lieved to contain less than 1 gram of albu¬ 
min per liter 20 c.c. instead of 10 c.c. of 
urine shoul-i be used, and where it ex¬ 
ceeds 4 grams, only 5 c.c. 

Lewin (Med. Klinik, July 13, 1913) em¬ 
phasizes the delicacy and reliability of the 
color reaction which follows when dis¬ 
solved albumin is treated with a mixture 
of 0.1 to 0.15 parts trioximinomethylen in 
100 parts crude sulphuric acid. Even a 
0.02 per cent, solution of egg albumin 
shows the characteristic violet tint. 

In the colorimetric method of Claudius, 
of Copenhagen, as described by Kahn and 
Silberman (N. Y. Med. Jour., Oct. 3, 1914) 
the urine is first filtered and its reaction 
tested to see if it is neutral or slightly 
acid. It is then diluted with an equal por¬ 
tion of a 2 per cent, sodium chloride solu¬ 
tion. To 5 c.c. of the diluted urine, add 
now 5 c.c. of Claudius’s reagent, which 
consists of 2 per cent, trichloracetic acid, 
0.5 per cent, tannic acid and 0.1 per cent, 
acid fuchsin. The mixture of urine and 
reagent is then well shaken in a stoppered 
15- or 20- c.c. flask, filtered, and the filtrate 
compared with a standard in the Sahli or 
Gowers hemoglobinometer. 

Norgaard (Ugeskrift for Laeger, Nov. 
25, 1915) has been giving Claudius’s quan¬ 
titative colorimeter test fcr albumin a 
thorough trial in 1(X) specimens of urine 
and in some other organic fluids, and 
found that by comparative tests, with an 
albumin content below 1 per thousand 
there may be a difference up to 10 per 
cent, of the findings on analysis by weight. 
With an albumin content above 1 per 
thousand, the difference could rise to 20 or 
30 per cent., averaging 2.5 per cent. C. 
E. DE M. S.] 

Miscellaneous.— D. iters (Miinch. med. 
Woch., Dec. 12, 1916) heats an ordinary 
test tube until the bottom is sufficiently 
soft to allow its being pushed up into the 
tube so as to make a small balUhaped or 
conical depression in its lower end. In 
this are poured 6 to 8 drops of nitric acid 


ALBUMINURIA (LEVISON AND ERLANDSEN). 


481 


and the urine poured on top. The tur¬ 
bidity resulting is more distinct than is 
obtained with the old test tube owing to 
the increase of light which passes through 
the fluid. 

Benedict (letter to the N. Y. Med. Jour., 
Nov. 28, 1914) describes the following 
simple method to estimate the albumin: 
Boil the urine thoroughly, adding 1 drop 
of nitric acid. Centrifugate until the pre¬ 
cipitate is no longer condensed. The per¬ 
centage reading is about 6 times the per¬ 
centage by weight of dried albumin. If 
the moist precipitate is large, say more 
than 1 c.c. (16 minims) in a 10-c.c. (214 
drams) tube, which rarely happens, even 
when urine is said to coagulate entirely, 
the lower portion of the precipitate is still 
further compressed. This method is sim¬ 
ple and rapid, and is reasonably accurate, 
sufficiently so for clinical use. 

A test described by Osmond (Lancet- 
clinic, Dec. 13, 1913) is asserted by him 
to be equal in delicacy to any other, and 
to have certain features which make it 
superior to them for routine use. The fol¬ 
lowing solution is employed: 


Picric acid . 5 parts 

Citric acid . 10 parts 

Sodium chloride . 100 parts 

Distilled water .KXX) parts 


Technique .—Place 2 or 3 c.c. of the re¬ 
agent in a test tube. Filter the urine until 
it is perfectly clear. Then allow urine 
very gently to float upon the surface of 
the reagent in the inclined test tube. Al¬ 
bumin will show as a white zone at the 
line of contact of the two amber fluids, 
which are practically iso-chromic. D. W. 
Prentiss (Med. Council, Aug., 1912) gives 
tile following method to record the amount 
of albumin in urine in such a way that it 
can be compared with later examinations 
in the same case, or with other cases. The 
record is permanent, easy to make, and 
sufficiently accurate to be of the utmost 
value to the busy physician: 1. Make the 
underlying nitric test for albumin, in a test 
tube. 2. Allow the tube to stand 2 min¬ 
utes. 3, Hold the tube between a black or 
dark object and the eyes, on the level with 
the eyes. 4. Note the exact thickness of 
the ring of albumin at the line of contact. 
5. On the chart draw parallel vertical lines 


which represent the test tube. Connect 
these lines by a cross line the exact breadth 
of the thickness of the coagulated albumin. 

H. E. Jones (Glasgow Med. Jour., Jan., 
1916) reports a case in which results of 
albumin determination in the urine with 
the Esbach procedure proved misleading, 
owing to a high degree of alkalinity of the 
urine tested. Although an albumin pre¬ 
cipitate was obtained in the heat and acid 
tests, no precipitate was obtained in the 
albuminometer owing to the fact that the 
amount of citric acid contained in Esbach’s 
reagent was insufficient to acidulate the 
urine to the extent required for precipita¬ 
tion of albumin by the picric acid in the 
reagent. In all very alkaline urine this 
source of possible error in the interpreta¬ 
tion of the test should be borne in mind. 

Lenk (Deut. med. Woch., Oct. 21, 1915) 
recommends the following rapid test for 
albumin and sugar. Albumin, enzymes, 
etc., are absorbed by negative substances 
like kaolin, charcoal, pulverized pumice 
stone, etc. If these are mixed with the 
urine after addition of Esbach’s reagent 
(a mixture of 5 Gm.—75 grains—picric 
acid with 10 Gm.—214 drams—citric acid 
in 500 c.c—1 pint—water) as the particles 
settle to the bottom of the dish they carry 
the albumin down with them. Using pul¬ 
verized pumice-stone, the albumin is pre¬ 
cipitated completely in 10 minutes. 

An improved technique for Tsuchiya’s 
phosphotungstic-hydrochloric acid-alcohol 
reagent for detecting albumin in the urine 
is offered by Sueyoshi (Mitteil. a. d. med. 
Fakul. d. k. Univ. Tokyo, xiv. No. 3, 1915). 
The reagent is a mixture of 20 Gm. mer¬ 
curic chlorid; 5 Gm. potassium bromid; 
10 C..C. hydrochloric acid (30 per cent.); 
water 55 c.c. and alcohol (95 per cent.) to 
100 c.c. The test tube is filled about half 
full of urine and about seven-eighths as 
m.uch of the reagent is poured in and 
thoroughly mixed with it. The albumin 
sediment is measured next day as usual. 

According to the writer, the forma¬ 
tion of picric acid crystals in 10 c.c. 
of urine treated with 5 c.c. of Es¬ 
bach’s reagent is a delicate test for 
albumin. A positive response throws 
light on the prognosis. The crystals 
are found more numerous as recovery 
progresses, either in acute or chronic 


1—31 






482 


ALBUMINURIA (LEVISON AND ERLANDSEN). 


kidney disease. The changes in the 
proportion of crystals always foretell 
the next stage of the disease. Bergell 
(Zeit. f. klin. Med., xc. No. 5-6, 1921). 

TREATMENT.— T. C. Janeway 
(Amer. Jour. Med. Sci., Feb., 1916; 
N. Y. Med. Jour., Feb. 12, 1916) stated 
that for the most part treatment in 
the past was purely schematic, based 
on a conventional diagnosis, and usu¬ 
ally involved violent interference 
with the habits of a lifetime. To tell 
every patient with albuminuria or 
hypertension to stop eating red meat, 
or, worse, to go on a diet, is evidence 
of ignorance. He divided the cases 
into 5 types. 

The first type is one in which albu¬ 
min and casts in the urine are the only 
evidence of disease. If the treatment 
of acute nephritis results in a steady 
subsidence of albuminuria, it should be 
persisted in, just as though the patient 
had a known acute nephritis, but if a 
week in bed on a milk diet has no ap¬ 
preciable effect on the albumin and 
casts, the bed and milk diet are an un¬ 
warrantable hardship. In children the 
question of a postural albuminuria 
should be cleared up without delay. 
The effect of exercise and cold baths 
should be studied carefully, as these 
may cause an albuminuria. Severe 
physical strain, exposure to cold and 
wet, and excesses, not only in tobacco 
and alcohol, but in other things as well, 
are to be avoided. Soups and spices 
may wisely be excluded from the diet. 
Gourmands should have their excessive 
appetites restrained; obese patients 
should be moderately reduced; but if 
the phthalein test is normal he sees no 
reason for a restriction of protein, 
either qualitative or quantitative, below 
a moderate normal intake. Patients 
who use much salt should reduce it. 


The second type is one m which the 
patients have hypertension with or 
without a trace of albumin and with 
slight if any subjective symptoms. The 
worst advice for a man of important 
affairs is to give up business com¬ 
pletely, but change of occupation may 
be imperative for the manual laborer. 
It is of great importance to secure ade¬ 
quate normal sleep. A short rest in the 
middle of the day is of great benefit. 
Tobacco in excess is a poison. While 
excessive athletics may be dangerous, 
exercise is beneficial, and when this 
cannot be allowed for any reason, mas¬ 
sage is helpful. Diet should follow 
about the same lines as in the first class, 
and the use of salt should be moderate. 
The abuse of fluid is dangerous and a 
winter vacation in a warm climate is 
sometimes desirable. 

The third type is that in which hyper¬ 
tension and outspoken myocardial in¬ 
sufficiency are present. The heart must 
be safeguarded by rest in bed or in a 
chair. Those with auricular fibrillation 
need digitalis, those without should 
also receive the drug, but some of them 
do not respond as well. Toxic effects 
must be watched for, as some patients 
with regular rhythm are made worse by 
digitalis. Then one of the caffeine 
diuretics should be tried, theocin, 
about 12 grains (0.77 Gm.) a day, or 
diuretin, about 40 grains (2.6 Gm.) in 
divided doses, not oftener than every 
other day. The fluid intake and the 
urine output must be measured accu¬ 
rately. Diuresis from digitalis should 
not be expected within 48 hours, but 
that from the caffeine group may be ob¬ 
served on the day of administration and 
the next doses should be given when the 
diuresis ceases. The symptoms that 
demand treatment are dyspnea, edema, 
and the whole picture of cardiac fail- 


ALBUMOSURIA. 


483 


ure with passive congestion of the vis¬ 
cera; vasodilators are indicated. He 
speaks highly of fresh nitroglycerin 
tablets dissolved on the tongue and 
not swallowed. 

Theobromine has been found to give 
good results in some cases. Regulation 
of the diet and reduction of fluids and 
salt are indicated. 

The fourth type is one of general 
edema without notable myocardial in¬ 
sufficiency. These patients excrete 
small quantities of salt, so treatment 
should always begin with a period of 
very low salt and water intake to pro¬ 
mote rapid absorption of the dropsy. 
Bed is desirable until normal function 
is restored, and if the dropsy disappears 
the further treatment is that of con¬ 
valescence from acute nephritis. Ob¬ 
stinate edema requires other dehydrat¬ 
ing measures, sweat baths, hot packs, 
perhaps purging. 

The fifth type is that of advanced 
renal insufficiency. Treatment is purely 
symptomatic. Paroxysms of dyspnea 
and of Cheyne-Stokes breathing de¬ 
mand special relief. Morphine is 
effective in many cases, but may in¬ 
duce anuria with coma. Chloral hy¬ 
drate in 5- or 10- grain (0.3 to 0.6 
Gm.) doses, alone or with bromides, 
sometimes is effective. The patients 
should be encouraged to sleep in a 
chair instead of insisting that they go 
to bed. 

Diet should be reduced to a minimum 
by the patient himself. Bleeding has 
its greatest value in sudden convul¬ 
sions, when the removal of 500 or 600 
c.c. of blood is indicated. Sweating 
occasionally is of benefit. 

F. Levison 

AND 

A. Erlandsen, 

Copenhagen. 


ALBUMOSURIA. — Albumose oc¬ 
curs in the urine under various circum¬ 
stances. It may appear when large quan¬ 
tities of pus, such as in empyema, a large 
abscess, etc., accumulate in any region; in 
chronic suppurative processes, intestinal, 
peritoneal, meningeal, etc.; in pyogenic 
nephritis, and when there is a consider¬ 
able destruction of white corpuscles. It 
may also indicate a more or less rapid 
tissue disintegration, caused by patho¬ 
genic organisms, as in pneumonia, particu¬ 
larly in the resolution stage; hepatic dis¬ 
orders, especially acute yellow atrophy. 
This form is usually temporary. 

The writer has encountered albu¬ 
mosuria in five pregnant women. It 
always disappeared a few days after 
delivery and did not seem to have 
any pathologic or prognostic import. 
Tanberg (Norsk Mag. f. Laegevidens- 
kaben, Jan., 1918). 

Case in a woman of 39 years, the 
outstanding points of which were 
the presence of the albumose in the 
urine, with a relative and total in¬ 
crease of small lymphocytes in the 
blood, and the absence of any signs 
of malignant growths, and cardiac 
enlargement, with murmur, and 
dropsy in the legs, together with the 
presence of streptococci in the urine. 
Heimann and Wilson (Lancet, Dec. 
28, 1919). 

In a rare form known as ^‘myelopathic 
albumosuria or Kahler's disease"' character¬ 
ized by a copious excretion of Bence- 
Jones proteose, the latter is persistent, 
and is usually associated with sarcoma¬ 
tous degeneration of the bone marrow. 
This form runs a rapid course and is in¬ 
variably fatal. A. Graham-Stewart (Clinv 
ical Jour., Mar. 29, 1916) observed 3 cases 
of albumosuria in children due to intes¬ 
tinal toxemia, with mucous colitis in one 
of the patients. Toxemia of intestinal 
origin is regarded by the author as an un¬ 
recognized cause of albumosuria. He 
urges the importance of an early dis¬ 
tinction between the latter and albumin¬ 
uria. Heller’s test for albumin then gives 
a bulky precipitate. This does not form 
with nitric acid so definite a ring as does 
albumin. It is more woolly and tends to 


484 


ALCOHOL (SAJOUS). 


float to the top. It may at once be dis¬ 
tinguished from albumin by heating when 
the ring or cloud disappears to reappear 
on cooling. Again the ordinary heat test 
does not cause albumose to form a cloud. 

Martindale gives the following tests for 
the detection of albumoses: Acidulate the 
specimen with acetic acid, and add 10 per 
cent, potassium ferrocyanide solution. 
This precipitates pri ary albumoses. This 
ferrocyanide precipitation distinguishes 
albumose from compound protein. On 
warming, the precipitate dissolves, to re¬ 
appear on cooling. This distinguishes it 
from that due to serum albumin. 

Again, after precipitation by salicylsul- 
phonic acid, albumoses dissolve on heat¬ 
ing and reappear on cooling. 

There is also the Biuret reaction. Albu¬ 
min is tested for by Heller’s test; if pres¬ 
ent, it is removed by 10 per cent, trichlor¬ 
acetic acid solution and the Biuret test 
applied to the filtrate. To do this, 1 drop 
of a 2 per cent, copper sulphate solution 
is placed in a test tube; 5 c.c. of the urine 
are added, and then 5 c.c. of a 10 per cent, 
solution of sodium hydroxide. The pres¬ 
ence of albumose is indicated by a rose 
pink. 

As regards the Bence-Jones form, Mar¬ 
tindale states that this albumose is de¬ 
tected by: Coagulating at 58® C., i.e., 
lower than serum albumin, which coagu¬ 
lates at 75° C.; precipitates with hydro¬ 
chloric acid; precipitates with nitric acid 
in the cold; on raising to the boiling- 
point, however, the coagulum dissolves 
more or less completely, and reappears on 
cooling; precipitates with potassium fer¬ 
rocyanide and citric acid (often takes time 
to develop, differing in this respect from 
albumin). 

The hypochloric acid test is stated to be 
very sensitive, and not to depend on ex¬ 
cess of salts. The result is obtainable 
after very free dilution of the specimen. 

S. 

ALCOH OL.— Alcohol is one of 
a group of hydrocarbon compounds 
which have as their base a radical desig¬ 
nated as ethyl, chemically represented 
by the formula C 2 H 5 . Alcohol is a hy¬ 
drate or hydroxide of ethyl—C 2 H 5 OH. 


To distinguish it from other more toxic 
members of the series of alcohols, par¬ 
ticularly fusel oil (chiefly amyl alcohol) 
and wood spirit (methyl alcohol), the 
spirit used in medicine is called ethyl 
alcohol. It is obtained by distillation 
and subsequent purification from a fer¬ 
mented mash of potatoes or grain, from 
fermented sugar, or from wine, and is 
known in the British Pharmacopeia as 
rectified spirit. 

Absolute alcohol, f.^., alcohol at least 
99 per cent, pure, occurs as a volatile, 
inflammable, colorless liquid, with a 
characteristic pungent odor and burn¬ 
ing taste. Its boiling point is 172° F. 
(77.7° C). It has a marked affinity for 
water, which it abstracts from whatever 
substances it may be in contact with, 
including the air and the human tissues. 
It is miscible in all proportions with 
water, glycerin, ether and chloroform. 
When absolute alcohol is mixed with 
water the resulting volume of fluid is 
slightly less than the sum of the two 
components before their admixture. 

Alcohol is a solvent for resins, 
volatile oils, fats, and alkaloids, and 
is very extensively employed as such 
in preparations containing remedies 
of these classes, most of which are 
insoluble in water. It forms the mens¬ 
truum in the official tinctures, spirits, 
elixirs, and all but two of the fluid- 
extracts. 

PREPARATIONS AND DOSE. 

Alcohol contains 94.9 per cent, by 
volume (92.3 per cent, by weight of 
pure ethyl alcohol to 5.1 per cent, of 
water). Specific gravity, 0.816. Rarely 
used internally in doses of 1 to 4 drams, 
diluted with water. 

Alcohol Dehydratum (Absolute Al¬ 
cohol) contains not more than 1 per 
cent, of weight of water. Specific 
gravity, 0.797. 


ALCOHOL (SAJOUS). 


485 


Alcohol Dilutum (Diluted Alco¬ 
hol).—A mixture of alcohol and dis¬ 
tilled water, containing 48.9 per cent, by 
volume (about 41.5 per cent, by weight) 
of pure ethyl alcohol to 51.1 per cent, of 
water. Specific gravity about 0.937. 

Spiritus Frumenti (Whisky), U. 
S. P. Vlll.—44 to 55 per cent, by 
volume of absolute alcohol. 

Spiritus Vini Gallici (Brandy), U. 
S. P. VIII.—46 to 55 per cent by vol¬ 
ume of absolute alcohol. 

Vinum Album (White Wine), U. 
S. P. VIII.—8.5 to 15 per cent, by 
volume of absolute alcohol. 

Vinum Rubrum (Red Wine), U. 
S. P. VIII.—8.5 to 15 per cent, by 
volume of absolute alcohol. 

Whisky is produced by the distillation 
of fermented grain (rye, corn, or bar¬ 
ley), and brandy by the distillation of 
fermented grapes. Inasmuch as the 
toxic amylic alcohol is likely to be pres¬ 
ent in freshly distilled spirits, the Phar¬ 
macopeia specifies that these products 
shall have been kept in storage for a 
certain period before use (whisky, two 
years; brandy, four years), the amylic 
alcohol becoming oxidized into harmless 
ethers. White wine results from the 
fermentation of the juice of fresh 
grapes, from which the skins, seeds and 
stems have been removed, while red 
wine is produced from purple-colored 
grapes with the skins included. The 
latter contains more tannin, but less tar¬ 
taric acid than white wine. 

Dose.—The ordinary dosage of 
whisky or brandy in adults unaccus¬ 
tomed to their use may be said to range 
from 1 dram (4 c.c.) to 2 ounces (60 
c.c). In regulating the dose the capac¬ 
ity of the individual to oxidize the alco¬ 
hol is to be taken into account, the object 
being, if alcohol is to be given repeat¬ 
edly, to limit the amount to that which 


can be destroyed in or eliminated from 
the organism in the interval between 
successive doses. According to Bartho- 
low, the quantity which a healthy adult 
is able to oxidize in twenty-four hours 
is from 1 to ounces of absolute al¬ 
cohol. Where this is exceeded, an accu¬ 
mulation of the drug in the system is 
likely to occur, and the following symp¬ 
toms may be expected to appear. Flush¬ 
ing of the face, dryness of the skin and 
mucous membranes, bounding pulse, and 
the odor of alcohol on the breath. Such 
signs indicate, in any given case, that 
the useful amount of alcohol, whether 
employed for general or merely for di¬ 
gestive stimulation, is being exceeded. 
In persons habitually taking alcoholic 
beverages the ability to oxidize alcohol 
is augmented, finding its expression in 
increased tolerance; hence in these indi¬ 
viduals, if alcohol is given for the pur¬ 
pose of obtaining therapeutic effects, 
the dose will have to be increased, and 
even, in many cases, doubled or tripled. 
In febrile states large amounts have 
often been administered without caus¬ 
ing signs of intoxication, the oxidizing 
power evidently being heightened dur¬ 
ing the febrile process; notwithstanding 
this fact, it is now generally considered 
that small doses of alcohol—if, indeed, 
it be used at all in these cases other than 
during periods of dangerous circulatory 
depression—will give as good results as 
large amounts. 

In children, as well as in the aged, 
alcohol is well borne. To the former it 
can be administered in doses proportion¬ 
ally larger than are suitable for adults, 
while in the latter the dose need not be 
reduced from that given to the middle- 
aged. 

MODES OF ADMINISTRATION. 

—Alcohol, as used in therapeutics, is 
usually exhibited in dilute form in one 


486 


alcohol (Sx\JOUS). 


of the various spirituous beverages, 
none of which is now official. They 
may conveniently be grouped according 
to the percentage of alcohol contained. 

The so-called “spirits” include whisky, 
brandy, gin, rum, and arrack, and all 
contain about 50 per cent, of alcohol. A 
liquor having this percentage is said to 
be “proof spirit,” implying that it con¬ 
tains just sufficient alcohol to be inflam¬ 
mable. Gin (“spiritus Genevse”) is 
made by adding oil of juniper berries to 
rectified alcohol or whisky. The offi¬ 
cial spiritus jiiniperi compositus, with 4 
per cent, of juniper oil as well as other 
flavoring substances, is a preparation 
similar to gin, but is stronger in alcohol, 
containing 70 per cent.; the average 
dose is 2 drams. Rum (“spiritus Jamai- 
censis”) is obtained by distilling fer¬ 
mented molasses or sugar. Like gin, it 
is not official. Arrack results from the 
distillation of fermented rice. Spirits 
contain a large number of other volatile 
bodies besides the main component, 
ethyl alcohol. These include higher 
members of the same group of alco¬ 
hols as ethyl alcohol, as well as alco¬ 
hols of other series and a group of 
bodies the composition of which re¬ 
mains obscure, known as the oenanthic 
ethers, and which, though present in 
small amounts, give to the various 
liquors their characteristic flavors. Spir¬ 
its differ radically from wines in that 
they are free of non-volatile compounds, 
which are left behind in the process of 
distillation. 

The heavy wines contain about 20 per 
cent, of alcohol, being made from grapes 
having a large proportion of sugar. 
They include port, sherry, Madeira, 
Marsala, Malaga, and others. Port 
(formerly official as “vinum portense”) 
is a sweet, red wine, containing 15 to 22 
per cent, of alcohol; its sweetness is due 


to arrest of the process of fermentation 
while still incomplete. Sherry (“vinum 
Xerici”) is a white wine, containing 15 
to 18 per cent, of alcohol. Port and 
sherry of American production are usu¬ 
ally lighter, the percentages ranging 
from 10 to 18. Madeira is a dark-col¬ 
ored white wine with 18 to 22 per cent, 
of alcohol. Marsala is a wine similar 
to Madeira, but of Sicilian production. 
Malaga is a sweet wine, having 17 per 
cent, of alcohol. The heavy wines are, 
in general, too sweet for the use of sick 
persons; when obtained “dry” (free, or 
nearly free, from sugar), however, they 
are frequently of benefit to convales¬ 
cents and to the debilitated. 

The light wines contain from 5 to 15 
per cent, of alcohol. Ordinary claret 
ranges from 6 to 12 per cent. This 
group also includes Burgundy, the Rhine 
wines, Moselle, Tokay, champagne, and 
hock, in all of which the percentage of 
alcohol is usually between 9 and 14. 
Champagne, though it contains only 
about 10 per cent, of alcohol, has a pro¬ 
nounced stimulating effect on the gastric 
mucous membrane because of the large 
amount of carbon dioxide it liberates. 
Wines are more slowly absorbed than 
alcohol, and the physiological effects of 
the alcohol they contain are correspond- 
ingly less marked. In addition, wines 
possess distinct nutritive value, by vir¬ 
tue of the numerous substances, both 
organic and mineral, which they em¬ 
body. These include, according to an 
analysis of red wine by Gautier, albu¬ 
minoid, fatty, and carbohydrate constit¬ 
uents, glycerin, potassium tartrate, suc¬ 
cinic acid, acetic, citric, malic and 
carbonic acids, and salts such as the 
chlorides, bromides, iodides, fluorides, 
and phosphates of potassium, sodium, 
calcium and magnesium oxide of iron, 
etc. Wine also contains a number of 


ALCOHOL (SAJOUS). 


487 


volatile bodies, such as are present in 
brandy in larger amount. Light wines 
are useful wherever prostration is or 
has been a marked feature of the case, 
c.g., in typhus, intermittent fever, 
scurvy, and cholera among the more 
acute diseases; also in many chronic af¬ 
fections, excluding, however, cases of 
Bright’s disease, chronic digestive dis¬ 
orders, neurasthenia, anemia, and dia¬ 
betes. Wines are peculiarly liable to 
undergo acetic fermentation in the 
stomach (Hayem), and hence are not 
well borne in certain gastric dis¬ 
turbances. It has been found in 
vitro that wines uniformly interfere 
with peptic digestion. Red wines 
very usually disagree where there 
is gastric hyperacidity. In these 
cases white wines are generally service¬ 
able. White wines have a diuretic ef¬ 
fect beyond that possessed by the red 
wines. When very acid, however, they 
are in themselves capable of causing 
gastric disorders, and should be avoided 
wherever diarrhea exists. Many of the 
Rhine wines are not suited to those 
having a tendency to the formation of 
oxalic deposits, owing to the oxalic acid 
which they contain. 

Malt liquors (beer, ale, brown stout, 
porter) contain less alcohol but have 
greater nutritive value than any other 
of the alcoholic beverages. They are 
produced by causing an extract of malt 
(sprouted barley grains) and hops to 
undergo fermentation by the yeast- 
plant. The malt is previously allowed 
to germinate, in order that the starch it 
contains shall be transformed into the 
more easily fermentable sugar. The 
diastase which effects this conversion is 
formed by the grain itself during germi¬ 
nation. The yeast then ferments the 
sugar with the production of alcohol. 
The final product contains about 3 to 7 


per cent, of alcohol and a large percent¬ 
age of solid constituents available for 
nutrition, including mainly dextrin, 
sugar; albuminoid, fatty and gummy 
substances; succinic, lactic and acetic 
acids; aromatic and bitter principles 
derived from the hops, carbon dioxide 
to the extent of 6 to 8 times the volume 
of the liquor, and a number of salts re¬ 
sembling those found in the ashes of 
meat extract, principally phosphates and 
salts of potassium and calcium (Man- 
quat). Beers also contain diastase, 
which aids in the digestion of carbohy¬ 
drate foods and tends to produce 
obesity. Ale differs from beer in that 
its fermentation is carried on at a high 
temperature instead of a low one; it 
usually has a higher percentage of 
alcohol, ranging from 4 to 8 or 9 per 
cent., while beer has 2 to 6 per cent. (4 
per cent, on the average). Porter and 
brown stout are fermented at a still 
higher temperature; some of the sugar 
is converted to caramel, giving these 
beverages their darker color. They 
contain 4 to 6 per cent, of alcohol. 

When the digestive powers are but 
little impaired, beer is valuable as a 
tonic and nutritive. The hops and the 
carbon dioxide probably both stimulate 
functionally the gastric mucosa. Where 
the digestion is weak, the large dextrin 
and sugar content of beer may undergo 
fermentation in the stomach. The ab¬ 
sorption of beer is, in any case, slower 
than that of other liquors. Beer diluted 
with water is said to be better borne 
than wines where there is hyperchlor- 
hydria. The low percentage of alcohol 
contained in beer renders it useful 
where the patient appears specially 
sensitive to the action of alcohol on the 
cerebrum. A syrupy extract of malt is 
official in the United States Pharma¬ 
copeia as extractum malti; it contains 


488 


ALCOHOL (SAJOUS). 


large proportions of dextrin, sugar, 
phosphates and nitrogenous bodies, and 
but 2 per cent, of alcohol. 

Less important medically are the 
wines of other fruits than the grape, 
and the liqueurs. Among the former 
may be mentioned cider, which results 
from the fermentation of apples and 
contains 2 to 5 per cent, of alcohol, and 
perry, a similar product made from 
pears. Cider is useful where diuretic 
and slightly laxative effects are desired. 
Liqueurs comprise a large class of 
alcoholic products differing widely in 
composition. They are generally made 
by the addition of essential oils; they 
frequently contain a large amount of 
sugar, and are of but little value in 
therapeutics. 

In acute diseases alcohol is usually 
given internally in the form of whisky 
or brandy. 

Under the Revenue Act of October 3, 
1917, which went into effect December 1, 
1917, every physician who wishes to buy 
alcohol U. S. P. for his own use must get 
a permit from the U. S. Internal Revenue 
Office, file a bond and state in his appli¬ 
cation blank for what purpose he intends 
to use the alcohol. This applies whether 
it is for washing his hands or for prepar¬ 
ing stains for laboratory use, or for any 
other purpose for which he desires to use 
grain alcohol without having it medicated 
or in some manner denatured. A physi¬ 
cian cannot purchase more than one pint 
of alcohol that has been medicated with¬ 
out obtaining a permit. Editors. 

C O N T R AINDICATIONS.— Al¬ 
cohol is contraindicated in nephritis and 
inflammatory conditions of the urinary 
passages, in conditions associated with 
marked gastric or intestinal irritation, 
and in persons likely to acquire the 
alcoholic habit,—especially young adult 
or middle-aged neurotics, and persons 
who have been subjected to traumatism 
of nervous structures. In prolonged 


cardiac depression alcohol is likely to 
do more harm than good. Sweet wines 
and beer are contraindicated in diabetes 
mellitus and in eczema. In the diar¬ 
rheas of children alcohol should not be 
administered unless the stomach and 
bowels have already been freed from 
putrefying material. 

' Syphilis' is always badly affected by 
alcohol, and the latter is responsible 
for many of the evil results often 
seen in this disease, both in the skin 
and in the nervous system. The 
syphilitic should be an abstainer from 
alcohol from the moment of his infec¬ 
tion. L. Duncan Bulkley (Med. Rec., 
Jan. 29, 1910). 

PHYSIOLOGICAL ACTION.— 

The effects of alcohol, when it is taken 
internally, vary according to the size of 
the dose. The action here to be de¬ 
scribed is that of therapeutic or some¬ 
what larger doses. 

Digestive Tract.—In the mouth 
and pharynx, alcohol has a slightly 
astringent action upon the mucous 
membranes. For a brief period it also 
causes an increased flow of saliva, and 
when in no greater concentration than 5 
per cent., has been found by Storck to 
favor the digestion of starchy foods by 
ptyalin. The action of ptyalin is, on 
the contrary, unfavorably influenced by 
alcohol in 10 per cent, strength and, 
more particularly, by the acids con¬ 
tained in malt beverages and wines. 

On reaching the stomach, alcohol 
produces a sense of warmth, which is 
promptly followed, as absorption takes 
place, by a general feeling of well-being 
and restfulness. When present in the 
stomach in small amount only, alcohol 
has no marked effect on peptic diges¬ 
tion, and often distinctly augments the 
secretion of gastric juice, itself becom¬ 
ing thereby progressively more dilute. 
It acts both by stimulating directly the 


ALCOHOL (SAJOUS). 


489 


gastric circulation and the secreting 
cells to greater activity, and probably 
also by a special secretory influence of 
the alcohol after its absorption. Since 
Spiro, Frouin and Moulinier observed 
that alcohol administered per rectum 
caused in the stomach a marked flow of 
abnormally acid gastric juice. Chitten¬ 
den and Mendel showed, moreover, that 
the relative amounts of pepsin and 
hydrochloric acid in the gastric juice 
were both increased. Thus alcohol in 
small quantities tends to hasten gastric 
digestion. Fatty substances being dis¬ 
solved by it, their absorption is facili¬ 
tated. The appetite, when poor, is 
improved. 

When 5 to 10 per cent, of alcohol is 
present, peptic digestion takes place 
less rapidly than normal, the degree of 
interference varying with the kind of 
food to be acted upon. According to 
Klemperer and Battelli, however, gastric 
motility is hastened by moderate 
amounts of alcohol, while Bandl, Scan- 
zoni and others have shown that liquids 
containing alcohol are much more 
rapidly absorbed from the stomach 
than liquids free of it. It thus happens 
in many cases that the interference of 
the alcohol with peptic digestion is more 
than counterbalanced by the hastened 
absorption as well as by the increased 
amount of gastric juice. Gluzinsky’s 
experiments indicate that alcohol slows 
gastric digestion only during the period 
before its absorption; it then causes in¬ 
creased rapidity of digestion because of 
the special stimulating efifect on secret¬ 
ing structures already mentioned. Ac¬ 
cording to this author 60 Gm. (about 
2 fluidounces) of cognac, taken during 
or before a meal, slows the digestion of 
carbohydrates and hastens that of 
meats, but when taken after the meal 
hinders both. It has been noticed that 


spirits are much less potent in hamper¬ 
ing peptic activity than are wines and 
especially malt liquors. In small quan¬ 
tities they distinctly aid digestion. 

Using the method first devised by 
Cannon, the writer studied experi¬ 
mentally the effect of alcohol on the 
rate of discharge from the stomach 
in the Laboratory of Physiology in 
the Harvard Medical School. A rela¬ 
tively small amount of alcohol mixed 
with the food administered to the 
animals had distinctly an accelerat¬ 
ing effect on the rate of gastric dis¬ 
charge and produced a higher maxi¬ 
mum than the normal. The gastric 
peristaltic waves were deep and 
vigorous, and in most cases at the 
end of 3 hours no residue remained 
in the stomach. Contrary to these 
results in the third set of experi¬ 
ments where the 95 per cent, alcohol 
was used there was a slow initial dis¬ 
charge and a gradual rise to a maxi¬ 
mum at the end of 3 or 4 hours. 
When at all evident the peristaltic 
waves were shallow and feeble and 
in some of the animals there was 
present at the end of 4 hours a con¬ 
siderable amount of food. L. T. 
Wright (Boston Med. and Surg. 
Jour., Nov. 2, 1916). 

Alcohol passes quickly from the 
stomach into the intestines. Here also 
it is absorbed, and exerts, when in 
small amount, an effect similar to that 
produced on the stomach, viz., stimu¬ 
lates the mucous and other glands to 
increased activity. Relaxation of the 
bowels and meteorism are frequently 
influenced by it. In vitro alcohol in 3 
per cent, strength, however, slows the 
digestion of proteids by the pancreatic 
juice (Chittenden and Mendel). 

Nervous System.—When the ac¬ 
tion of alcohol has been exerted long 
enough, it acts as a depressant to the 
nervous system. The effects seen at 
first suggest primary cerebral stimula¬ 
tion, but it is a question whether these 


490 


ALCOHOL (SAJOUS). 


phenomena are not really the result of 
impaired inhibition, in which case alco¬ 
hol might be said to act as a depressant 
from the beginning. Small amounts of 
alcohol do, indeed, produce effects sug¬ 
gesting loss of inhibitory control over 
cerebral activities, though it must be 
admitted that the actual physiological 
existence of such a controlling function 
has not yet been definitely proved. In 
the primary stage of apparent excita¬ 
tion, the subject exhibits loss of con¬ 
trol, as manifested by loose speech, 
laughter upon slight provocation, out¬ 
bursts of the passions and exaggerated 
movements. The subject becomes self¬ 
ish, irresponsible, and lacks will-power. 
Bunge, Schmiedeberg and others be¬ 
lieve that these phenomena occur be¬ 
cause the normal inhibitory influence 
on the cortical centers has been reduced. 

Alcoholism may be assumed, the 
writer concludes, when besides the 
lesions of chromatolysis in the third 
layer of large pyramidal cells of the 
brain, there is dilatation or conges¬ 
tion of the capillaries, thickening of 
the meninges, without leucocyte in¬ 
filtration, and small hemorrhages. 
Jones (Prensa Med. Argentina, Sept. 
30, 1918). 

As an argument against the theory 
of primary stimulation it is pointed out 
that a primary stage of excitement is 
usually not seen when the subject re¬ 
mains in quiet and dark surroundings 
after taking alcohol, while certain indi¬ 
viduals show no evidences of stimula¬ 
tion under any circumstances, but soon 
pass into a state of cerebral depression. 
Other observers believe that the physi¬ 
cal excitement and the unusual flow of 
ideas and powers of speech often ob¬ 
served under the influence of alcohol 
indicate a primary stimulating effect on 
the same centers. The ability to per¬ 
form muscular work has usually been 


found in experiments to be increased 
for a brief period by alcohol in small 
amounts, especially where fatigue ex¬ 
ists, but this is very promptly followed 
by a distinct decrease; further, it is not 
proven that the preliminary increase is 
due to excitation of the motor areas, 
since the nerves or muscles themselves 
may instead have been affected. Krae- 
pelin concluded from his experiments 
that motor activities were heightened 
by alcohol in small amounts and de¬ 
pressed by larger quantities, but that 
the mental activities were lowered for 
a period of twelve to twenty-four 
hours by it even in small doses. Alco¬ 
hol acts also on certain sensory centers, 
reducing pain. 

Marchiafava was the first to call 
attention to primary degeneration of 
the nerve fibers in the corpus cal¬ 
losum and commissure in men with 
alcoholic psychoses. The clinical pic¬ 
ture in this condition is that of a 
gradually developing feebleminded¬ 
ness, with perversion or deadening ot 
the moral sense; there may also be 
tremor and disturbances in speech, 
etc. Guizzetti (Riforma Medica, Apr. 
24, 1915). 

Blix’s test of the orientation capac¬ 
ity of the hand as a means of de¬ 
termining the amount of disturbance 
induced by small amounts of alcohol 
was applied by the writer. The test 
amount of alcohol was always 5 c.c., 
taken before rising, and the exercise 
was done 50 minutes later. There was 
always a falling off of from 20 to 50 
per cent, when the alcohol was taken. 
C. Gyllensward (Upsala Lakareforen- 
ings Forhandlingar, 22, No. 3, 1917). 

In order to test the mental effects 
of alcohol, dotting machines were 
used for “attention” and lists of re¬ 
lated words for “memory.” It was 
found that the general effects of al¬ 
cohol were to deteriorate these pow¬ 
ers except under certain fatigue con¬ 
ditions, when alcohol improved both 
powers; opium, on the contrary, im- 


ALCOHOL (SAJOUS). 


491 


proved both powers, whether under 
normal or fatigue conditions. The 
fatigue was engendered by loss of 
sleep for 3 nights. The tests were 
made every day. The more dilute 
the alcohol, the weaker the effect; 
alcohol taken after a meal had a much 
less evident result’ than when taken 
4 or 5 hours after a meal. Smith and 
McDougall (Trans. Brit. Assoc. Adv. 
of Sci.; Med. Rec,, Oct. 2, 1920). 

After the initial stage of apparent 
stimulation, the actual depressant action 
of alcohol on the nervous system is no 
longer in doubt. Soldiers have been 
found to march better and remain 
stronger without alcohol than when 
supplied with it in moderate amounts. 
Large single doses produce signs of dis¬ 
tinct brain depression, passing from 
muscular inco-ordination, with imper¬ 
fect speech, impaired sensibility, and 
somnolence, to a state of unconscious¬ 
ness similar to that of ether and chloro¬ 
form anesthesia. The spinal cord is 
depressed by alcohol even before the 
unmistakable signs of cerebral depres¬ 
sion occur, as shown by the early 
muscular inco-ordination (apart from 
disturbances of equilibrium) and dimin¬ 
ished reflex irritability. The functions 
of the bulbar centers, however, are not 
markedly affected until late. On the 
peripheral nerves alcohol in large doses 
was found by Dogiel to exert a pro¬ 
nounced depressing effect in dogs. 
Motor nerves are believed to withstand 
this effect longer than sensory nerves. 
In the frog the response of the motor 
nerves to stimuli is at first increased 
when the vapor of alcohol is brought in 
contact with it, but the usual depressant 
action soon follows. 

At the Nutrition Laboratory of the 
Carnegie Institution an exhaustive 
experimental study of the physiologic 
consequences of the ingestion of 
small doses of ethyl alcohol in man 


showed that it induced no facilitation 
of the motor processes, but that the 
depression of the simplest forms in 
the finger and eye movements 
seemed to be one of the most char¬ 
acteristic effects of alcohol. It is ex¬ 
actly these effects which were found 
to harmonize most closely with the 
average of all the effects for the sev¬ 
eral subjects studied. F, G. Benedict 
(Jour. Amer. Med. Assoc., Apr. 29, 
1916). 

Circulation.—Although the pulse- 
rate is commonly increased after the 
use of alcohol in considerable amount, 
Jacquet believes that where the subject 
can be kept free from external exciting 
influences, no such change in the heart- 
action is produced. The results of ex¬ 
periments intended to develop the action 
of alcohol on the heart have been con¬ 
tradictory. It is thought by many that 
the mammalian heart is slightly stimu¬ 
lated by alcohol unless given in large 
amounts, when it is depressed (Dixon 
and Bachmann, Wood and Hoyt, Loeb, 
Bachen). Alcohol in 2 per cent, 
strength passed through the coronaries 
of a cat’s heart does not cause arrest 
of cardiac activity (Loeb). Other 
experimenters conclude that alcohol 
causes no increase in the work per¬ 
formed by the heart. According to 
Cushny the preliminary action of alco¬ 
hol is to weaken the heartbeats. As 
for the blood-pressure, moderate doses 
have usually not been found to alter it. 
The advocates of primary cardiac 
stimulation by alcohol account for this 
by the dilatation of the peripheral 
blood-channels, which is often manifest 
in the flushed face, injected conjunc- 
tivae, and heated skin surfaces observed 
after the use of alcohol. The speed 
with which the blood courses through 
the vessels is thereby increased (Hem- 
meter, Wood and Hoyt). Whether the 
vascular dilatation is due to an action 


492 


ALCOHOL (SAJOUS). 


on the vasomotor centers or on the 
vessels themselves has not as yet been 
determined. The results include dis¬ 
turbances in the cerebral circulation; 
the brain may be the seat either 
of marked hyperemia or of anemia 
(Claude Bernard). Certain experi¬ 
menters have at times observed in¬ 
creased blood-pressure due to alcohol; 
thus Kochmann noted in man a rise in 
the pressure upon the exhibition of 5 
to 10 c.c. (1^ to drams) of abso¬ 
lute alcohol. Such an elevation of 
pressure might be due either to a 
direct stimulating effect on the vaso¬ 
motor centers, or, as many believe, 
to a reflex effect on these centers due 
to irritation of the gastrointestinal 
mucous membranes. 

Report concerning a series of mano- 
metric blood-pressure tracings show¬ 
ing the effect of alcohol on dogs. By 
mouth it caused a marked rise in 
blood-pressure, with increased ampli¬ 
tude and a constant, or slightly 
slowed rhythm of heart beat. This 
rise gradually passed off in 5 or 10 
minutes. By whatever method ad¬ 
ministered, alcohol, circulating in the 
blood, causes a gradual, progressive 
lowering of blood-pressure with de¬ 
crease in amplitude but increase in rate 
of heartbeat. Clyde Brooks (Jour. 
Amer. Med. Assoc., July 30, 1910). 

Though whisky raises for a few 
moments the systolic blood-pressure, 
it decreases secondarily cardiac effi¬ 
ciency, raises disproportionately the 
diastolic pressure, and lowers the 
pulse' pressure. C. C. Lieb (Jour. 
Amer. Med. Assoc., Mar. 13, 1915). 

The writer found experimentally 
that when alcohol is given orally to 
an unanesthetized animal there is a 
rapid rise in blood-pressure and res¬ 
piratory rate and an immediate return 
to normal. This is due to local ac¬ 
tion. Given intravenously, gradually, 
in quantities sufficient to kill in 1 or 
2 hours, no effect occurs until just 
before death, when a rapid fall of 


pressure takes place. When given 
through a stomach tube there is no 
effect. When it is given intravenously 
without excitement in the normal 
dog, no stimulation of the heart or 
respiration can be observed. Hyatt 
(Jour. Laborat. and Clin. Med., Oct., 
1919). 

Excessive amounts of alcohol cause 
a pronounced fall in the blood-pressure, 
since they depress both the heart and 
the vasomotor center. They have also 
been observed in animals to slow the 
heart action, and even produce cardiac 
arrest, in much the same manner as 
does chloroform. According to Pou- 
chet, the secondary fall of blood-pres¬ 
sure is due largely to stimulation of 
the inhibitory pneumogastric centers ; 
the pressure may, indeed, at a certain 
stage of the poisoning be brought al¬ 
most back to normal by section of the 
vagi. 

The ingestion of alcoholic bever¬ 
ages, even in small amounts, during 
or just after work, in which calcium 
cyanamide is used, induces special 
symptoms illustrated in the following 
typical case; An emphysematous 
worker, aged 55, who was occupied in 
breaking up cyanamide, took 0.3 liter 
of red wine at 11:25 a. m. In 3 min¬ 
utes the pulse rate rose from 69 to 
104, the blood-pressure fell from 160 
to 110, and the rate of breathing rose 
from 16 to 22. Already in the second 
minute there was excessive vasodila¬ 
tation of the face and conjunctivas, 
marked pulsation of the temporals, 
then nausea; the man was compelled 
to stay recumbent, becoming faint as 
soon as he attempted to rise. The 
pressure remained 110 for an hour, 
then rose slowly. The signs of vaso¬ 
dilatation passed off in about an hour. 
The sensitiveness to alcohol from 
working with cyanamide lasts over 18 
hours after cessation of work, though 
diminishing during this period; it 
then disappears completely, even in 
individuals who have long been work¬ 
ing in the factory. J. P. Langlois 


ALCOHOL (SAJOUS). 


493 


(Bull, de I’Acad. de med., July 2, 
1918). 

Blood. —Large amounts of alcohol 
must be present to cause perceptible 
changes in the blood in a short space of 
time. Foguet claimed to have ascer¬ 
tained that intoxicating doses, taken 
daily, were without effect. Pouchet 
states, however, that under small, re¬ 
peated doses, the blood gradually under¬ 
goes fatty changes, owing to the fact 
that the emulsified fats entering the 
blood with the chyle are not consumed 
as normally. 

A research on the cholesterol and 
lecithin content of the blood of dogs 
kept under the action of alcohol, 
showed that besides the unusually 
high content of the blood in these 
bodies, the neutral fat of the blood is 
also increased. There seems to be 
an actual mobilization of the lipoids, 
a lipoidolysis, perhaps the expression 
of a defensive function. Ducceschi 
(Prensa Med. Argentina, Oct. 10, 
1918). 

In addition to the above changes the 
alkalinity of the blood is lowered, the 
coagulability rises, and a process of 
dehydration goes on, as shown by diure¬ 
sis and increased secretions generally, 
whereby the blood becomes relatively 
more concentrated, the erythrocyte 
count and hemoglobin percentage ris¬ 
ing. Schmiedeberg found that blood 
containing alcohol loses in part its 
oxygenating power,—a fact of con¬ 
siderable practical significance. In 
vitro, alcohol added to blood darkens its 
color, coagulates it, and causes hemo¬ 
globin to leave the erythrocytes. Such 
effects can only be obtained in the 
animal organism by the intravenous in¬ 
jection of alcohol in large doses. Under 
these conditions the red cells undergo 
marked changes in shape and color 
(Hayem). The fats and lecithin are 
dissolved, and the hemoglobin becomes 


dissociated from the stroma and pre¬ 
cipitated in reddish, refractile droplets. 
Bordet and Massart showed alcohol to 
have a strong negative chemotactic in¬ 
fluence on the white blood-cells, even 
when greatly diluted. 

Microscopic changes in the tissues 
as a result of alcohol, taken from ob¬ 
servations on animals: 1. The most 
marked effects are produced on the 
blood-vessels. 2. The cells which 
line the vessels are swollen and 
broken, and there are serious retro¬ 
grade changes in all of the tissues. 
The white blood-cells become swol¬ 
len and necrotic. 3. The lymph- 
spaces become choked with broken- 
down white blood-cells, and the small 
blood-vessels are also completely 
blocked by plugs in detritus and dead 
tissue. 4. In the veins the blocking 
is often so severe that the vessels 
burst from the backing up of blood in 
them. The changes are always more 
marked in the vessels of the brain 
than elsewhere because they do not 
possess the special nerves which con¬ 
trol their caliter, as do the vessels 
of other parts of the body. H. J. 
Berkley (Johns Hopkins Hosp. Bull.; 
Amer. Jour, of Physiol. Therap., May, 
1910). 

Respiration. — Volumetric estima¬ 
tions made before and after the inges¬ 
tion of alcohol have shown fairly con¬ 
clusively that, even in the absence of 
motor excitement, the drug causes an 
increase in the amount of air breathed. 
Usually the augmentation is more pro¬ 
nounced in fatigued or exhausted 
individuals. Considerable experimenta¬ 
tion has been indulged in for the pur¬ 
pose of ascertaining whether the drug 
stimulates directly the respiratory cen¬ 
ters in the medulla or whether the 
effect is of indirect origin, viz., through 
irritation of the gastric mucosa. Thus 
Loewy conducted experiments in which 
the irritability of the centers of respira¬ 
tion before and after the use of alcohol 


494 


ALCOHOL (SAJOUS). 


was ascertained through its response to 
an increase of carbon dioxide in the 
blood. The results of these and other 
researches have not been entirely con¬ 
clusive, but, in a general way, they tend 
to show that alcohol exerts, in man at 
least, little if any direct central stimula¬ 
tion, and therefore, that the improve¬ 
ment in respiration observed under the 
influence of therapeutic doses of alco¬ 
hol is probably due to a reflex effect on 
the centers. An additional argument in 
favor of the latter view is in the fact 
that respiratory depression occurs only 
under exceedingly large doses of alco¬ 
hol and at a late stage in the poisoning, 
tending to show that the effect of this 
drug on the respiratory centers is, under 
ordinary circumstances, not a very 
marked one. Yet it is well known that 
in the final stage of acute alcoholic 
poisoning the breathing becomes more 
and more shallow and infrequent, com¬ 
plete arrest ultimately occurring. 

In fever, both the respiration and the 
heart-rate are slowed by alcohol. This 
seems reasonably accounted for by a 
lessening of general bodily excitement 
through the narcotic action of alcohol, 
without implicating a direct depressing 
action of moderate doses of it upon 
both the respiratory centers and heart. 

Secretions.—Many of the secre¬ 
tions are to a certain extent activated 
by alcohol. The saliva and digestive 
secretions are increased reflexly by the 
local action of alcohol on the mucous 
membranes, as well as, probably, after 
its absorption, through direct contact of 
alcohol with the gland-cells as the drug 
circulates with the blood-stream. The 
sweat secretion is increased owing to 
the peripheral vasodilatation. The 
urine is also augmented. The question 
whether a direct exciting action on the 
renal epithelium is exerted or not has not 


yet been settled, though the fact that 
albuminuria may result from excessive 
doses would seem to point to an irrita¬ 
tive effect on the kidney cells. 

Temperature.—Alcohol in ordinary 
doses causes a slight fall in the body 
temperature (34° to 1° C., according to 
Cushny), owing to the dilatation of the 
superficial blood-vessels, which exposes 
a larger amount of blood to the cooling 
influence of the surrounding air. At 
the same time a sensation of warmth 
is experienced, and the temperature of 
the skin may rise considerably owing to 
its flushed condition. If a large amount 
of alcohol be taken the fall of internal 
temperature may be exaggerated owing 
to the complete motor inactivity. The 
same will occur under a moderate dose 
of alcohol if the subject be subsequently 
exposed to cold. 

Metabolism.—Alcohol causes but 
little change in the oxygen intake and 
carbon dioxide output, which, after its 
ingestion, show no modification beyond 
that to be expected from any other sub¬ 
stance yielding energy to the system by 
oxidation. Of course, if alcohol be 
taken in amounts sufficient to produce 
sleep, the respiratory gaseous inter¬ 
changes will be lowered because of the 
muscular inactivity. Where the drug is 
taken repeatedly in moderation, how¬ 
ever, a gradual increase in the oxidizing 
power of the blood occurs, apparently 
corresponding in amount to the degree 
to which tolerance of alcohol has been 
developed in the individual. This fact 
was well illustrated in the experiments 
of Hunt on the toxicity of methyl 
cyanide, a compound whose poisonous 
effect is proportional to the extent to 
which it is oxidized to hydrocyanic acid 
in the system. Animals given repeated 
small doses of alcohol, insufficient in 
themselves to elicit signs of intoxication, 


ALCOHOL (SAJOUS). 


495 


showed an increased susceptibility to 
methyl cyanide, demonstrating that the 
oxidizing power of the blood had be¬ 
come greater. 

The effect of alcohol on respiration 
was studied by the writer on recum¬ 
bent and breakfastless men. From 
30 to 45 c.c. (1 to 1^ ounces) of 
ethyl alcohol (suitably diluted) were 
given. The respiration rate was not 
appreciably affected by alcohol nor 
was the type of respiration changed, 
unless there was restlessness. The 
heat production, as indicated by the 
oxygen consumption, was ordinarily 
unchanged; in about one-fifth of the 
experiments there was a rise in heat 
production of from 5 to 7 per cent. 
It diminished the volume of air 
breathed per minute in most in¬ 
stances. Higgins (Jour. Pharm. and 
Exper. Therap., May, 1917). 

In addition, the administration of 
alcohol, which is almost entirely de¬ 
stroyed in the system by oxidation, 
naturally tends to preserve from com¬ 
bustion other oxidizable substances 
present—fats in particular. This ac¬ 
counts for the well-known fattening 
tendency of alcoholic beverages, when 
habitually taken in any but very moder¬ 
ate amounts (see section on Alcohol in 
Nutrition). 

Immunity.—As to the influence of 
alcohol on the powers of resistance 
of the individual to disease, it is 
well known that alcoholics are less 
resistant to acute infections and 
more susceptible to dangerous shock 
from bodily injury than are the 
temperate. Likewise, animals given 
alcohol and subsequently inoculated 
with pathogenic organisms or in¬ 
jected with disease toxins have al¬ 
ways shown a low degree of resistance 
as compared to normal animals. Del- 
earde and Laitinen in their experiments 
found it “almost impossible to confer 
immunity against rabies, tetanus, and 


anthrax on alcoholized animals.” The 
question, however, whether alcohol in 
the amounts in which it has been used 
in the treatment of acute febrile dis¬ 
eases in non-alcoholics has a similar 
prejudicial effect has not been definitely 
settled. 

[Inasmuch as the defensive power of 
the body fluctuates with its vital activity, 
beverages rich in alcohol, besides inhibit¬ 
ing the life process itself, place it at the 
mercy of disease-breeding germs, and thus 
actually help to destroy life through de¬ 
oxidizing or reducing action on the blood. 

This is further emphasized by the in¬ 
fluence of alcohol on the ductless glands 
themselves. While small doses or weak 
solutions, as stated by Lorand, stimulate 
these organs, large quantities of beverages 
strong in alcohol cause their degeneration, 
as shown by numerous autopsies. My 
work on the “Internal Secretions” contains 
a microphotograph showing a pituitary 
body in which alcohol produced sclerosis. 
Hertoghe and de Quervain have found 
alcohol harmful to the thyroid—an organ 
which, as is well shown by cretinism and 
the marvelous effects of thyroid prepara¬ 
tions in this disease, has much to do with 
the development of the body. The defen¬ 
sive functions of the body, if carried on, 
as I hold, by the ductless glands, are thus 
directly hampered by the use of alcohol in 
any but very weak solutions. This coin¬ 
cides with the recent observations of 
Parkinson, who studied the influence of 
alcohol on the autoprotective functions of 
the body. While his experiments showed 
that small quantities temporarily enhanced 
the production of antibodies, as soon as 
they were replaced by large doses the 
opsonic index fell; and if their use was 
continued, it remained low permanently, 
which meant that the immunizing func¬ 
tions were paralyzed. This confirmed the 
earlier experiments of Muller, Wirgin, and 
others referred to below. 

It is because of this fact that drunkards 
in general fare so badly in infectious dis¬ 
eases; their autoprotective mechanism is 
powerless to defend them. Quite in accord 
with these teachings of experience, Par¬ 
kinson found that the reaction to vaccines 
was much less effective in alcoholized rab- 


496 


ALCOHOL (SAJOUS). 


bits than in normal rabbits, and that the 
difference was still more marked when 
living micro-organisms were used. Many 
experiments by competent observers afford 
evidence in the same direction. Again, I 
have shown that the immunizing process 
of the body is closely linked and runs on 
parallel lines with oxidation; since alcohol 
in anything but small doses reduces oxida¬ 
tion, it inhibits in proportion our power 
to fight disease during the active or de¬ 
fensive phase of the morbid process, espe¬ 
cially in febrile infections and toxemias. 

If alcohol is used at all, therefore, in 
the acute infections and toxemias, it 
should only be given in small quantities 
and freely diluted. But better agents to 
enhance the defensive process are now 
available. C. E. de M. S.] 

Friedberger, Muller, Wirgin, and 
other observers found that, in rabbits, 
the administration of alcohol for some 
days in amounts sufficient to pro¬ 
duce a mild degree of intoxication 
interferes with the formation of 
antibodies in the blood. The greater 
the time allowed to elapse, how¬ 
ever, between the injection of the 
antigen and the giving of alcohol, 
the less the restraining eflfect of the lat¬ 
ter on the development of protective 
substances. Experiments conducted by 
Laitinen, in which animals were given 
for some time doses of alcohol so small 
as to correspond with the amounts 
taken dietetically by moderate users of 
alcohol, did not reveal any pronounced 
disadvantage in the habitual use of 
small quantities of alcohol as regards 
susceptibility to disease, the mortality 
being but slightly greater than among 
the animals not given alcohol. 

Ingestion of alcohol is quickly ac¬ 
companied by a lowered opsonic in¬ 
dex, but the index as quickly returns 
to the normal with cessation of the 
alcohol. The amount needed to bring 
about this result had no influence on 
the resistance of the animal to infec¬ 
tion. Abbott and Gildersleeve (Univ. 
pf Penna. Med, Bull., June, 1910), 


Study of protein metabolism and 
utilization, and especially the parti¬ 
tion of nitrogen in the urine, under 
the influence of alcohol, carried out 
on man and dogs under fixed and 
comparable conditions of diet. There 
is no pronounced disturbance in the 
alimentary utilization of the food¬ 
stuffs. Moderate doses exert a pro¬ 
tein-sparing action, which is suc¬ 
ceeded by loss of nitrogen when 
larger quantities of alcohol are ad¬ 
ministered. The partition of urinary 
nitrogen remains remarkably unal¬ 
tered, with the exception of an in¬ 
creased elimination of ammonia nitro¬ 
gen and a higher output of purins. 
The most significant impression af¬ 
forded was the absence of pronounced 
alterations indicative of markedly dis¬ 
turbed protein metabolism, even when 
comparatively large doses were con¬ 
tinued for days and weeks. Mendel 
and Hilditch (Amer. Jour, of Physiol., 
Nov., 1910). 

[As is the case with all food accessories, 
coffee, tea, pepper, common salt, etc., al¬ 
cohol becomes toxic when used immod¬ 
erately, and when insufficiently diluted. 
Light wines, beer, and other beverages 
that contain a very small proportion of 
alcohol, when taken in moderation, tend 
to activate the functions of the ductless 
glands, and, therefore, the autoprotective 
functions of the body. The harmful in¬ 
fluence of alcohol begins as soon as the 
proportion of absolute alcohol in a bever¬ 
age exceeds 5 per cent, to any marked 
degree, the toxic effects being due mainly 
to its property of becoming oxidized at 
the expense of the blood and other body 
fluids and cellular elements. When the 
proportion exceeds 10 per cent, and ap¬ 
proximates that of brandy, whisky, and 
many patent or proprietary nostrums, al¬ 
cohol becomes an active toxic; it tends to 
paralyze the functions of the ductless 
glands, and, therefore, the autoprotective 
functions, thus giving free sway to patho¬ 
genic germs, their toxins and other toxics, 
venoms, toxic wastes, etc., that may be 
present in the blood, thus defeating in¬ 
directly and insidiously the efforts of the 
physician. C, E, DE M. S.l 


ALCOHOL (SAJOUS). 


497 


The study of necropsies at the Bos¬ 
ton City Hospital on cases dying 
from alcoholism during the 15 years 
previous to 1915, shows that the 
great majority of alcoholics show no 
change except an abundance of fat in 
the liver cells. The writer found 
that 30 investigators gave ethyl alco¬ 
hol to animals, and of these 17 pro¬ 
duced no lesions in the liver, while 
13 claimed to have produced cir¬ 
rhosis; those that produced cirrhosis 
worked with rabbits. To clear up 
this question the writer gave alcohol 
persistently to 125 animals, including 
guinea-pigs, cats, rabbits and dogs, 
and in no instance could any lesions, 
however slight, be produced. Other 
substances than alcohol were also 
given to a series of 75 animals, with 
essentially negative results. The 
writer believes that the so-called 
alcoholic cirrhosis is not produced by 
alcohol, and that the liver is not in¬ 
jured by the alcohol carried to it by 
the blood or lymph. F. A. Mcjunkin 
(Arch. Internal Med., May, 1917). 

Absorption and Elimination.—The 
absorption of alcohol is very rapid, 
unless it be so concentrated as to coagu¬ 
late the albumins with which it comes 
in contact. Roughly, 20 per cent, of 
alcohol ingested is absorbed from the 
stomach, and the remaining 80 per cent, 
from the intestine. Proceeding to the 
liver with the portal blood, it is in part 
arrested in this organ, the other portion 
passing through to enter the general 
blood-stream. Eventually much of the 
latter portion leaves the capillaries by 
exosmosis and is absorbed by the 
various tissues. The liver and brain 
have a special affinity for alcohol, the 
former fixing four times and the latter 
twice as much as is present in the blood 
(Pouchet). More than 98 per cent, of 
the whole amount ingested is oxidized 
in the tissues (Atwater). The re¬ 
mainder passes out with the urine un¬ 
altered, though traces may still remain 


in the blood after the first twenty-four 
hours. The aroma of the breath of 
alcohol users is due rather to higher 
alcohols and by-products eliminated in 
this manner than to ethyl alcohol 
(Cushny). According to Brauer, some 
alcohol is excreted with the bile, then 
reabsorbed from the intestinal tract. 
An insignificant amount may leave the 
body with the sweat and milk. The 
products of the oxidation of alcohol in 
the system are believed to be acetic acid, 
carbon dioxide, and water. According 
to the researches of Dujardin-Beaumetz 
and Jaillet, it is oxidized in the red cells 
themselves, with the formation first of 
acetates of the alkali metals, then of 
carbonates. When the oxidizing ca¬ 
pacity of the blood-cells is exhausted 
alcohol begins to be eliminated in large 
amount with the emunctories and to 
accumulate in the tissues. 

Role of Alcohol in Nutrition.—The 
painstaking experiments of Neumann, 
of Atwater and Benedict, and of Rose- 
mann have shown alcohol to be capable 
of sparing the fats and carbohydrates 
of the body through its combustion in 
their stead, i.e., where the amounts of 
fat and carbohydrates ingested are in¬ 
sufficient for the needs of the body alco¬ 
hol will, to a certain extent, act as a 
substitute, and prevent the remaining 
reserve of these substances in the system 
from being exhausted. The combus¬ 
tion of alcohol, however, yields but a 
comparatively small amount of heat, 
the body temperature being, therefore, 
seldom raised by it, but rather lowered, 
owing to the peripheral vasodilatation 
it also produces, with the consequent in¬ 
crease in heat loss. Neumann con¬ 
cluded from his experiments that alco¬ 
hol could take the place of a chemically 
equivalent quantity of fat in the diet, 
and also that alcohol given in combina- 

1-32 


498 


ALCOHOL (SAJOUS). 


tion with a diet in itself sufficient would 
bring about an economy of proteins— 
as measured by the nitrogen excretion 
in the urine—in the same way that an 
extra amount of fat would. When 
moderate amounts of alcohol are taken, 
the first result is an increase in the 
amount of nitrogen excreted, which 
persists, as in the case of any other 
change in the non-nitrogenous constit¬ 
uents of the food, until the organism 
has become used to the new diet, i.e., 
through a period of three or four days. 
After this the protein-saving property 
of alcohol asserts itself, the amount of 
urea and uric acid, as well as of sul¬ 
phates and phosphates, eliminated with 
the urine showing a decrease. Accord¬ 
ing to Pouchet, however, the proteins 
are spared by alcohol only if the subject 
is receiving in the diet an amount of 
protein .in excess of the needs of the 
body at the time. If not, or in any 
case if the administration of alcohol 
be long enough continued, the amount 
of nitrogenous wastes will soon show 
an increase until the utilization of the 
body proteins becomes greater than 
nOirmally—a condition of affairs un¬ 
favorable to the nutrition of the body. 
The same result will obtain at once 
where excessive, instead of moderate, 
doses of alcohol are used, tihe drug 
acting as a spur to the breaking down 
of the albumins. 

The advantages of alcohol as a source 
of body energy may be said to lie in its 
ready absorption, the fact that no diges¬ 
tion of it is required, and that it is easily 
oxidized. In fever or conditions of 
central nervous exhaustion, with result¬ 
ing temporary digestive failure, alcohol 
is, therefore, available for cautious use 
as a food. Roughly speaking, 4 min¬ 
ims of alcohol will yield the same 
amount of energy as 7 grains of 


sugar, starch, or protein or 3 grains 
of fat (Committee of Fifty, 1893). 

The disadvantages of alcohol are that 
it has toxic side effects, that it leads to 
obesity, and, probably, that, even in the 
temperate, it tends to lower the resist¬ 
ing power of the body to disease. • 

[Alcohol is considered as a food-sparing 
agent by some observers, its value corre¬ 
sponding with its dynamic equivalent of 
pure food hydrocarbon. This presupposes, 
however, that alcohol is utilized by the 
tissues in the same manner as these hy¬ 
drocarbons—merely because its oxidation 
liberates energy in the form of heat. But 
this is a fallacious conception; alcohol 
only simulates normal oxidations; far 
from being the product of cellular ex¬ 
changes which constitute the vital process, 
the heat it liberates is at the expense of 
the tissue, since by becoming oxidized 
itself, especially in the liver—whereby the 
body is protected against its toxic effects 
—it utilizes oxygen intended to sustain 
tissue metabolism. If alcohol were a food, 
large doses would prove more profitable 
to the organism than small ones; but the 
reverse is the case; large doses inhibit all 
activities that would be enhanced by a 
liberal use of food. The debilitating 
action of alcohol on the nervous system, 
for example, has been demonstrated by 
Bunge, Schmiedeberg, Ach and Krepelin, 
and others, while Dogiel found that it de¬ 
pressed markedly both motor and sensory 
nerve-centers. It does this not only with 
nervous tissue, but with all tissues. A 
depressing agent cannot logically be re¬ 
garded as a food. C. E. de M. S.] 

In healthy persons alcohol unques¬ 
tionably plays the same role as a food, 
e.g., a carbohydrate or a fat. In con¬ 
trast to fats and carbohydrates, alco¬ 
hol spares the proteids only in those 
cases in which the organism has be¬ 
come accustomed to the action of the 
stimulant, which usually takes sev¬ 
eral days. In disease alcohol appar¬ 
ently acts upon metabolism in the 
same way as in health. It is particu¬ 
larly useful as a food in diabetes mel- 
litus; by taking the place of fats in 
the food it lessens the production of 


ALCOHOL (SAJOUS). 


499 


the acetone bodies. Hare showed 
that alcohol raises the power of the 
blood to destroy bacteria. Fried- 
berger found that under the influence 
of alcohol the blood acquired an in¬ 
creased resistance against the cholera 
vibrio. Mircoli found that under the 
influence of alcohol the body acquired 
the power to resist the tubercle bacil¬ 
lus. A. K. Sievert (Roussky Vratch, 
Oct. 24, 1909; N. Y. Med. Jour., Jan. 1, 
1910). 

[The protective influence of alcohol re¬ 
ferred to here applies to small quantities 
only. Everyone knows and hospital ex¬ 
perience has amply and conclusively shown 
that alcoholism greatly weakens the power 
of the body to resist disease. C. E. de 
M. S.] 

Industrial fatigue, i.e., a diminished 
capacity for doing work relative to 
the taking of alcohol was studied by 
the writer. He concludes that alco¬ 
hol has little immediate effect upon 
the physical side of fatigue, whatever 
its ultimate effect may be. The 
amount of output is perhaps in¬ 
creased to a small extent for a short 
time, but the increase soon falls off 
and is replaced by a diminution. The 
influence of alcohol in the psychical 
side of fatigue was more profound. 
It led immediately to a feeling of re¬ 
newed vigor and increased strength. 
But here also the effect was transi¬ 
tory. A. F. Stanley Kent (Lancet, 
July 28, 1917). 

External Action.—Applied to the 
skin and allowed to evaporate, alcohol 
reduces the local temperature because 
of its marked volatility. It may also 
exert an anesthetic effect. If evapora¬ 
tion be prevented, however, and the 
contact maintained for some time, alco¬ 
hol acts as an irritant. Owing to its 
rather high diffusion power, it pene¬ 
trates through the cuticle to the un¬ 
derlying tissues, and induces a sen¬ 
sation of heat, often preceded by 
itching and accompanied by red¬ 
dening of the skin surface. It may 
thus be employed as a counter¬ 


irritant. For such effects a concentra¬ 
tion of about 60 per cent, or over is re¬ 
quired, more dilute solutions not giving 
rise to distinctly irritative phenomena. 
When applied to ulcers and other open 
surfaces, alcohol may, through its irri¬ 
tant properties, hasten tissue repair. 
The prominent local effects of concen¬ 
trated alcohol include the abstraction of 
water from the tissues, and the coagula¬ 
tion of albumin. It is because of these 
effects, and also by dissolving out the 
fat, that alcohol hardens the skin when 
repeatedly applied. It is sometimes 
used to cover sores or wounds with a 
thin, protective, air-excluding layer of 
coagulated albumin, which facilitates 
healing. Alcohol may also act as an 
astringent, a property not infrequently 
availed of in such condition as saliva¬ 
tion, pharyngeal relaxation, scurvy, etc., 
alcoholic preparations being employed 
as mouth-washes and gargles. The irri¬ 
tant and astringent powers of alcohol 
are naturally more pronounced upon the 
mucous membranes and upon wound 
surfaces than upon the skin, and dilute 
preparations can, therefore, be used on 
the former to procure effects such as 
only concentrated ones would produce 
on the skin. Inhalation of the vapors 
of alcohol is capable of causing tempo¬ 
rary spasm of the laryngeal muscles 
through reflex irritation. Alcohol has 
noteworthy antiseptic and germicidal 
properties, which may be utilized in the 
disinfection of wounds. According to 
Harrington and Walker, 60 and 70 per 
cent, alcoholic solutions, applied to 
wounded surfaces for at least five 
minutes, are the most efficient in de¬ 
stroying bacteria. In these percentages 
alcohol corresponds in strength to about 
3 per cent, phenol (Cushny). Dry 
bacteria may not be destroyed by a day’s 
exposure to absolute alcohol. 


500 


ALCOHOL (SAJOUS). 


THERAPEUTICS. —As a “Stim¬ 
ulant.” —The opinion of the medical 
profession in regard to the value of 
alcohol as a stimulant is divided, and 
the extent to which the drug is em¬ 
ployed in the treatment of disease (ex¬ 
ception being made of its external uses) 
is on the decline. 

The more recent studies have brought 
out the importance of the vasodilator 
influence of alcohol, and cast a shadow 
on its effectiveness as a true stimulant. 
By many it is believed that a part, if 
not all, of the stimulating effect of 
alcohol results from the local irritation 
produced by it in the stomach, the 
centers in the medulla oblongata being 
thereby excited reflexly. 

[Buchner, Chittenden, Mendel, Jackson, 
and many other authorities have shown 
that beverages which contain a small pro¬ 
portion, about 5 per cent., of absolute 
alcohol, such as light wines, beer, etc., 
increased the production of gastric juice 
and the activity of the digestive process. 
Being entirely oxidized in the stomach and 
promptly eliminated by the lungs and kid¬ 
neys, this small percentage, unless taken 
in large quantities, does not influence 
morbidly either the blood or its oxidizing 
body. Such is not the case, however, when 
the proportion of absolute alcohol exceeds 
5 per cent, to any marked degree. A 
beverage containing 10 per cent, for ex¬ 
ample, retards digestion manifestly, and if 
stronger, as is the case with brandy, 
whisky, etc., it tends besides, as first 
shown by Claude Bernard, to cause coagu¬ 
lation of the gastric secretion and its fer¬ 
ments. Under these conditions, the func¬ 
tions of the digestive tract are not alone 
interfered with, but considerable alcohol 
is absorbed into the blood. It is this 
absorbed alcohol which does incalculable 
harm. Being oxidized at the expense of 
the blood’s oxidizing body—of adrenal 
origin—it robs the tissues of that which 
sustains their life. C. E. de M. S.] 

Experience of many years has 
taught the writer that there are no 
harmful effects from the strictly mod¬ 


erate (his italics) use of alcohol by 
persons of sound mental and physical 
health, such as British soldiers sup¬ 
posedly are. He agrees with Mer- 
cier and Lyon Smith that asylum 
statistics tend to show that insanity 
produces inebriety, and not vice 
versa, as is so frequently averred by 
the zealous champions of total ab¬ 
stinence. J. W. Astley Cooper (Lan¬ 
cet, Nov. 14, 1914). 

Partly because of the fact that it is 
often the only remedial agent imme¬ 
diately available, it is still largely admin¬ 
istered, especially by the laity, in all 
varieties of emergencies. Its effect, 
though of short duration, is exerted 
promptly. 

No amount of whisky will lead to 
intoxication when its effect is needed 
to combat sepsis, and his cases 
of thorough sepsis relieved or cured 
by alcohol extend over more than 
half a century. Among these were 
cases of diphtheria with mixed infec¬ 
tion where his experience had shown 
that no such infection was amenable 
to the action of antitoxin. A. 
Jacobi (Amer. Med., Sept., 1913). 

At the Venice hospital connected 
with the medical school no harm re¬ 
sulted from the complete discarding 
of wine and brandy. The educational 
effect from the suspension of alcohol 
was excellent and widespread. Even 
the elderly chronic cases seemed to 
do just as well without it, and 78 
per cent, assured the investigators 
that they did not feel the loss of the 
wine as a privation. The others 
seemed to miss it only as an agree¬ 
able relish. Jona (Policlinico, Nov. 
11,'1917). . 

As a cardiac and respiratory stimu¬ 
lant alcohol is made use of in imme¬ 
diately dangerous conditions, such as 
syncope, shock, collapse, severe hem¬ 
orrhage, asphyxia, and poisoning by 
depressant drugs, as well as, in many 
instances, in the course of acute in¬ 
fectious diseases, such as typhoid 
fever, typhus, pneumonia, diphtheria, 


ALCOHOL (SAJOUS). 


501 


small-pox, scarlatina, septicemia, ery¬ 
sipelas, tetanus, yellow fever, cholera, 
dysentery, influenza, etc. The con¬ 
sensus of present opinion is that 
alcohol should never be administered 
continuously, even in severe infec¬ 
tions, but should be reserved for 
periods of unusual depression, when 
special stimulation is necessary to tide 
the patient over a dangerous crisis. In 
selecting the dose to be used, the vaso¬ 
dilator influence of alcohol must al¬ 
ways be remembered, excessive doses 
tending to lower markedly the tone 
of the blood-vessels,—the importance 
of which tone in the maintenance of 
cardiac activity is well recognized. 
According to many, indeed, the use 
of alcohol in shock is to be avoided, 
as this is a condition of paretic vaso¬ 
dilation, and the vasodilator effect of 
alcohol exerted after its absorption is 
likely to prove more harmful than its 
primary reflex stimulating effect on 
the heart and respiration will have 
done good. The same applies in 
severe hemorrhage. 

For each gram of alcohol oxidized 
in the body 7 large calories of heat 
are produced. Glucose, on the other 
hand, yields but 4.1 large calories of 
heat for each gram similarly con¬ 
sumed. Thus, alcohol, with no ex¬ 
penditure of digestive energy, and 
with the expenditure of less oxygen, 
yields a much larger production of 
heat and energy. It has great power 
for good when the system is in a 
pathological condition or greatly de¬ 
bilitated from any cause and cannot 
secure the necessary heat and energy 
from the ordinarily used food ele¬ 
ments. Like food substances, alco¬ 
hol is a stimulant, but, in addition, it 
can be oxidized in the body when 
sugar and fat cannot be so utilized. 

Many lives have been saved by the 
proper use of alcohol in times of 
dire need. No one has yet proved 
that alcohol cannot be used so as to 


secure a stimulating effect without 
developing any of the subsequent de¬ 
pressing action. It would be a great 
mistake to drop so valuable an agent 
from the pharmacopeia. W. H. Por¬ 
ter (N. Y. Med. Jour., Apr. 3, 1920). 

In emergency conditions, large 
doses of alcohol, e.g., 1 or 2 ounces 
(30 to 60 c.c.) of whisky or brandy, 
are not infrequently administered. 
Where, owing to unconsciousness or 
profound adynamia, the spirits can¬ 
not be swallowed, they may be injec¬ 
ted subcutaneously. By this method 
absorption of the drug is more rapid, 
and its general effect correspondingly 
hastened. Alcohol may also be given 
by rectum, preferably as brandy. 

In the treatment of wounds inflicted 
by venomous snakes and poisonous 
fishes, the internal use of alcohol has 
long been considered an effective 
measure, though the dea that the drug 
exerts a specific antidotal effect in 
these cases appears to be based on 
pure assumption. Large doses are 
customarily given in these cases, but 
this should certainly not be pushed 
to the point of adding an acute intox¬ 
ication to the difficulties with which 
the system already has to contend. 

In the prostration attending cases 
of meat poisoning or ergotism, the 
administration of alcohol also often 
proves valuable. 

As a Vasodilator.—The value of al¬ 
cohol in feverish or frankly febrile 
conditions depends in reality on not a 
single, but a group, of effects, which 
have been enumerated by Sollmann as 
follows: 1. Dilatation of the cutaneous 
vessels. 2. Counteraction of the nerv¬ 
ous phenomena of fever, through nar¬ 
cotic action. 3. The furnishing of a 
readily absorbable food. 4. Diuresis. 
Among these effects peripheral vaso¬ 
dilation ranks as the most important. 


502 


ALCOHOL (SAJOUS). 


When the pulse becomes of the hig-h- 
tension variety, owing to excitation of 
the contractile vascular walls by dis¬ 
ease toxins, and the superficial circula¬ 
tion becomes sluggish, for the same 
reason, alcohol is likely to prove bene¬ 
ficial by dilating the vessels, lowering 
the tension, facilitating the work of the 
heart, and promoting perspiration. It 
will act thus pre-eminently as a restorer 
of the circulatory equilibrium. Certain 
particular indications for the use of 
alcohol in fevers have been formulated, 
viz., where in addition to a frequent, 
small, or irregular pulse or respiratory 
depression there are present dryness of 
the tongue and skin, together with rest¬ 
lessness and delirium or, on the other 
hand, indifference and 'hebetude, and 
perhaps subsultus tendinum,—phenom¬ 
ena commonly grouped under the term 
“typhoid state.” While, in a general 
way, the validity of these indications 
for alcohol seems to be established upon 
the basis of past experience, it cannot 
be said that the drug will invariably be 
productive of benefit where the indica¬ 
tions are present. If, alcohol having 
been administered, the pulse and res¬ 
piration are improved, the mouth and 
skin rendered moist, and the mental 
condition corrected, the propriety of 
employing it in the individual case 
will become apparent. 

As a vasodilator in chronic high 
arterial tension alcohol should or¬ 
dinarily not be used. This indication 
is present in arteriosclerosis and gout, 
and is a symptom and sign in late 
middle life or old age. If the con¬ 
dition requires treatment it is much 
better managed by nitroglycerin, thy¬ 
roid extract, potassium iodide, or 
small doses of chloral. If arterioscle¬ 
rosis is present and the patient is 
well along in life and is accustomed 
and has been accustomed to take al¬ 
cohol regularly in doses that do not 


intoxicate, it may be unwise to stop 
the vasodilating effects of the alco¬ 
hol until it has been ascertained that 
some other treatment will be as con¬ 
ducive to his well-being. In other 
words, the physiological relief from 
high tension which he has been 
accustomed to acquire by taking alco¬ 
hol cannot be abruptly stopped with¬ 
out- due consideration of the conse¬ 
quences of withdrawing the drug. 
(Jour. Amer. Med. Assoc., Nov. 6, 
1909). 

The dose of alcohol given in the feb¬ 
rile diseases has usually been that rep¬ 
resented by to 1 ounce (15 to 30 c.c.) 
of whisky or brandy, diluted with water, 
this amount being repeated every two 
to four hours. While it has been a mat¬ 
ter of common observation that very 
large doses of alcohol may be given in 
fever without eliciting the ordinary 
signs of intoxication, this fact should 
not be interpreted as giving the physi¬ 
cian license to introduce alcohol into 
the systems of patients without due 
consideration of the dosage. It should 
be kept in mind that alcohol, though set¬ 
ting free energy in the form of heat 
through its oxidation, in doing so draws 
upon the supply of oxygen present in 
the tissues, and if caused to accumulate 
in the system through injudicious 
dosage is likely seriously to interfere 
with other oxidative processes essential 
to the welfare of the economy. Hence 
the tendency recently has been, if alco¬ 
hol is used at all in fever, to limit 
strictly the amount given to what is 
necessary for amelioration of the 
symptoms. 

According to Osborne, a dose larger 
than 1 to 3 teaspoonfuls, once every 
three hours, is probably never indicated 
in febrile conditions; if this dosage be 
exceeded, the harmful efifects resulting 
when alcohol is given in amounts that 
overtax the oxidizing powers of the 


ALCOHOL (SAJOUS). 


503 


tissues and lead to accumulation of the 
drug in the system will be avoided. 
Butler counsels that, even in cases 
where alcohol proves beneficial, it 
should rarely be given throughout the 
twenty-four hours, but reserved for 
periods when the heart action grows 
especially weak, usually in the interval 
between midnight and 7a.m. One fluid- 
ounce (30 c.c.) of whisky may be given 
before midnight and repeated every 
three hours. In lieu of pure whisky or 
brandy, diluted alcohol may also be ad¬ 
vantageously given in the form of milk 
punch or eggnog. 

Alcohol is frequently used to in¬ 
crease the warmth of the body surface 
in the presence of chilly sensations or 
after exposure to cold. This is accom¬ 
plished through the peripheral vaso¬ 
dilation which it produces. It must 
not be forgotten, in this connection, that 
peripheral vasodilation results in in¬ 
creased heat loss; if, during exposure to 
cold, peripheral vasodilation be pro¬ 
duced and maintained for some time, as 
by repeated ingestion of alcohol, the 
result cannot but be an excessive loss of 
body heat, with merely temporary re¬ 
lief, and ultimate lessening of the resist¬ 
ing powers. Hence alcohol to warm the 
body surface should only be given after 
exposure or just before the period of 
exposure is to terminate. 

In the initial stage of colds and of 
acute catarrhal inflammations of the 
respiratory passages in general, alco¬ 
holic preparations have been much used 
with the idea that by sharply activating 
the circulation of blood at the periphery 
local congestions will be relieved and the 
cold thus aborted. The patient takes 
a good-sized dose of. whisky, followed 
by smaller doses every three or four 
hours, and stays in bed for a day, to 
facilitate the re-establishment of the 


circulatory equilibrium. While there is 
no doubt that alcohol, in combination 
with external warmth, will often bring 
about the desired result, the same ef¬ 
fect can be procured by means of a hot 
bath, a coal-tar drug, and a saline pur¬ 
gative, without resorting to the use of 
alcohol. 

In arteriosclerosis alcohol will act as 
a vasodilator and doubtless frequently 
performs this office in elderly individuals 
accustomed to its use, but it should 
never be prescribed as such by the 
physician. 

Where the eruption is delayed in 
the acute exanthematous diseases, a 
dose of whisky, taken hot, may bring 
about its early appearance. 

As a Narcotic and Hypnotic,—The 
slightly depressing action of moderate 
doses of alcohol on the cerebral func¬ 
tions is a contributing factor in its use¬ 
fulness in febrile conditions. Mild de¬ 
lirium will be relieved by it, or if no 
delirium be present the oncoming of 
sleep will be favored. The narcotic 
action of alcohol, however, is only of 
secondary importance, and should not 
be utilized unless there are other indica¬ 
tions for the use of the drug. In febrile 
states a part of the quieting effect on 
the brain is due to a lowering of the 
tension in the cerebral circulation 
through the general vasodilation which 
the drug produces. 

In mild degrees of insomnia in the 
aged, a little alcohol taken before retir¬ 
ing will promote sleep. But it is pref¬ 
erable to use other remedies; thus 
where the insomnia, as is often the case, 
is due to high blood-pressure, nitroglyc¬ 
erin should be substituted for alcohol, as 
a vasodilator. A mixture of equal parts 
of hot milk and of good ale or beer has 
been recommended as a promoter of 
sleep. 


504 


ALCOHOL (SAJOUS). 


Although alcohol in proper dose and 
in the proper form has an hypnotic 
effect not only by dilating the peripheral 
vessels and relieving the tension of the 
cerebral circulation, but also by its 
quieting effect on the nervous system, it 
should not frequently be considered or 
used as a hypnotic. Still, instances 
occur both in acute illness and in de¬ 
bilitated patients where it seems to be 
the safest and the most satisfactory of 
hypnotics. Of course, when alcohol is 
used thus as a drug it should be stopped 
by the physician as soon as he considers 
that the patient can tolerate another 
hypnotic, or that the positive indication 
has ceased to exist. In very old people 
who cannot sleep, alcohol as a “night¬ 
cap” has been frequently advised. 
Sleeplessness in senility is frequently 
due to high-tension circulation, and one 
can often cause these patients to sleep 
as well with small doses of nitro¬ 
glycerin, administered at bedtime, as by 
alcohol so administered. (Jour. Amer. 
Med. Assoc., Nov. 6, 1909.) 

Similarly, in insomnia in greatly 
weakened individuals, where alcohol 
may seem, for a time, the best hypnotic 
to use, other drugs should be substi¬ 
tuted for it as soon as the patient’s 
general condition permits. Beer or 
well-diluted spirits are most effective 
where the hypnotic action of alcohol is 
desired. 

In neuralgia as well as melancholia 
and other forms of mental distress alco¬ 
hol has given relief through its nar¬ 
cotic effect, but the danger of inducing 
chronic alcoholism in these cases is such 
that it is questionable whether it should 
ever be employed. 

As a Stomachic, Antemetic, etc.— 

Ingested before or during meals, alco¬ 
holic preparations will frequently exert 
a pronounced beneficial effect in cases 
of atonic dyspepsia or in anorexia or 
poor digestion due to physical or mental 
fatigue, acute illness, etc. A small 
amount of wine or beer, or a little 


brandy diluted with water, by exerting 
a mild stimulating effect locally im¬ 
proves the gastric circulation and there¬ 
by promotes the secretory activity where 
this is deficient. The psychic effect of 
the odor and taste of wine, when agree¬ 
able to the patient, probably also plays 
a not inconsiderable part in improving 
the appetite. Dry wines should be 
given the preference in these cases, the 
sugar of sweet wines being detrimental. 
Where anorexia is very marked, bitter 
tonics, such as calumba or quassia, in 
the form of tinctures or gentian or cin¬ 
chona, in the compound mixtures, may 
be given in addition. 

In certain forms of indigestion, alco¬ 
hol does more harm than good, e.g., 
where there is hyperacidity, or where 
the gastric mucosa is acutely inflamed. 
In all cases, moreover, where the neces¬ 
sity for gastric stimulation is likely to 
persist, e.g., in the chronically debili¬ 
tated and in the neurotic, the use of 
alcohol as a stomachic and stimulant to 
digestion is to be entered upon only 
with extreme caution, lest chronic alco¬ 
holism be the final result. This danger 
is less to be feared in the aged than it 
is in the young or middle-aged. 

In vomiting, e.g., in seasickness and 
in the vomiting of pregnancy, alcohol, 
especially in the form of champagne, 
sometimes proves helpful. A little 
brandy may be given on cracked ice in 
these disturbances, but champagne is 
decidedly the most effective preparation, 
combining the local anesthetic property 
of alcohol with the sedative action of 
carbon dioxide gas. In a somewhat 
similar manner, the pain resulting 
from flatulence, as well as gastralgia, 
may be relieved by the use of brandy 
(Butler). 

In diarrhea, brandy is generally be¬ 
lieved to exert a favorable influence. 


ALCOHOL (SAJOUS). 


505 


though the reason for its beneficial ef¬ 
fect is not known. Red wines, by virtue 
of their tannin content, also tend to 
counteract diarrhea,—especially Bor¬ 
deaux, dark Burgundy, and currant 
wine. 

In conditions of general debility and 
during convalescence from exhausting 
diseases, even in the absence of gastric 
symptoms, alcoholic preparations are 
frequently given as general stimulants 
and reconstructives. The benefit pro¬ 
duced results in part, doubtless, from 
activation of the digestive processes, but 
the food value of the preparations used, 
generally rich red wines, such as port 
and Madeira, or else beer, ale, porter, 
brown stout, and malt extracts, because 
of the additional nutritive substances 
they contain, must also be given due 
credit. To these favorable influences 
may be added the tendency to sleep and 
rest as a result of the narcotic action of 
alcohol, the improved distribution of 
blood through peripheral vasodilatation, 
the lessened resistance to cardiac action 
offered by the vessels, and the euphoria 
of the primary stage of alcoholic action. 
In severe cases of diabetes mellitus 
alcohol has also been used as a food. 

Use of alcohol as a food in cases of 
severe diabetes. For years its value in 
such cases has been known clinically. 
But until recently we did not know 
whether the action was pharmacological 
or whether it was nutritive. In 1906, 
Benedict and Torbk, in studying the 
origin of acetone bodies in diabetes, 
substituted the fat of the dietary by 
alcohol and found a marked decrease 
in the output of acetone, sugar, and 
nitrogen. The sugar alone decreased 
18 per cent. In severe cases with high 
ammonia the output was greatly de¬ 
creased. Their work added further 
evidence of the protein-sparing action 
of alcohol. Neubauer, simultaneously, 
found alcohol of great service in severe 
diabetes. He used a wine containing 


10 per cent, alcohol, allowing daily 12 
to 24 ounces, equivalent to 450 to 900 
calories of energy. He found regularly 
in severe cases a marked reduction in 
the output of sugar, acetone, oxybutyric 
acid, and ammonia. The total nitrogen 
and the amount of urine were decreased. 
In light cases of this disease, alcohol 
was of much less importance, but in 
severe diabetes, where the tissues can¬ 
not utilize carbohydrates, where only a 
little or no fat is allowable, and where 
protein alone tends to aggravate the 
conditions, alcohol finds an invaluable 
place in the dietary. Aside from its 
action in diabetes and a few conditions 
of malnutrition, there has been no 
evidence produced thus far that alcohol 
is a better food than the sugars and 
starches. There is some reason to 
believe it somewhat inferior to them. 
There is abundant evidence that, on 
account of its habit-producing power 
and its baneful effects when used in 
excess, it should be condemned as food 
for healthy, normal individuals. Scar¬ 
brough (Yale Med. Jour., Feb., 1910). 

As a Diuretic.—Dilute gin, light 
acid white wines, and light beers are the 
most strongly diuretic preparations of 
alcohol. This property can, however, 
only be considered as a relatively unim¬ 
portant adjunct to the other actions of 
alcohol. 

In Phenol Poisoning.—The value 
of alcohol in phenol poisoning has been 
shown to be due to the ready solubility 
of the phenol in it, the local action of 
phenol in concentrated form being 
thereby hindered. It is to be observed 
that this very dilution of the phenol is 
likely to hasten its absorption into the 
general system. Hence after giving the 
alcohol—preferably dilute—the physi¬ 
cian should see that the stomach is 
emptied as soon as practicable. 

External Uses.—Applied locally, 
alcohol has antiseptic, anesthetic, cool¬ 
ing, stimulating, solvent, astringent, 
dehydrating, and hemostatic proper- 


506 


ALCOHOL (SAJOUS). 


ties. It is, therefore, a valuable agent 
in the treatment of wounds, espe¬ 
cially infected wounds, in the man¬ 
agement of which whisky, undiluted 
or diluted in the proportion of 1 to 4 
of water, may be employed with ad¬ 
vantage. In snake-bites concentrated 
alcohol mixed with ammonia may be 
used as a lotion after the poison has 
been sucked out; it is similarly use¬ 
ful in insect stings. In puerperal 
sepsis 50 per cent, alcohol has been 
used as an intra-uterine douche, and in 
25 to 50 per cent, strength as a packing; 
better agents are, however, at our dis¬ 
posal. 

For the treatment of sprains, in¬ 
flamed join^, contusions, strained 
muscles and tendons, headache, neu¬ 
ritis, abscesses, slight burns, ery¬ 
thema, and erysipelas, alcoholic evap¬ 
orating lotions are extensively used. 
A lotion composed of alcohol 8 parts, 
ammonium chloride 1 part, vinegar or 
dilute acetic acid 4 parts, in water 
64 parts, will be found generally 
serviceable. Where a greater degree of 
absorption is desired, a gauze pad may 
be moistened with alcohol, applied over 
the involved area, and covered with rub¬ 
ber tissue. In phlegmonous inflamma¬ 
tions, Salzwedel cleanses the part with 
ether, applies thick layers of cotton 
saturated with 90 per cent, alcohol, and 
covers the whole with an impermeable 
material, perforated in such manner as 
to delay, but not entirely prevent, evapo¬ 
ration. By this plan, he states, fever is 
lowered and the suppurative process 
hastened. Similarly, in sycosis, furun¬ 
culosis, indolent ulcers, whitlow, etc., 
Heuss employs compresses consisting of 
6 to 8 folds of gauze wet with 95 per 
cent, alcohol and covered with an imper¬ 
meable dressing. Kaiser employed alco¬ 
hol dressings in 93 cases of various 


inflammatory affections, and claimed 
very gratifying results; the distinctive 
feature of this method was that as a 
preliminary step, all fatty matter is re¬ 
moved from the involved area with 
benzine and alcohol (Bulkley). 

Permanent applications of strong al¬ 
cohol of great service in combating all 
inflammatory conditions in which 
there is a tendency toward suppura¬ 
tion. It causes a local dilatation of 
the blood-vessels, and thereby the 
formation of alexins and consequent 
greater capacity for resisting the 
spread of infection. Thick layers of 
gauze are saturated with alcohol and 
then covered with some impervious 
material. The dressing is left in place 
for days at a time, resaturating 
it with alcohol once every twelve 
hours. Graeser (Miinch. med. Woch., 
July 17, 1900). 

Following combination recommended 
as a clean and effective substitute for 
the ordinary lead and laudanum dress¬ 
ing 

Morphine acetatis .. 0.65 Gm. (1 gr.). 

Liq. plumbi subace- 
tatis . 30 c.c. (1 oz.). 

Alcoholis ...q. s. ad 120 c.c. (4 oz.). 

M. Sig.: Apply on 1 layer of muslin 
or cotton and allow to evaporate. 
W. Brady (N. Y. Med. Jour., April 24, 
1909). 

The benefit derived from the use of 
the tincture of arnica in sprains, and 
spirit of camphor in mastitis, seems to 
depend entirely on the cooling produced 
by the rapid evaporation of the alcohol 
contained in these preparations. The 
benefit derived from the popular “alco¬ 
hol rub” is entirely a matter of sugges¬ 
tion, and its supposed strengthening 
properties are mythical. Alcohol is not 
absorbed when rubbed on the skin. 
When used in this way in depressed 
conditions, it is liable to do harm, by 
reducing the body temperature when it 
should be sustained. Olive oil or cacao 
butter should be used instead of alcohol 
in massage. G. A. Graham (N. Y. 
Med. Jour., May 8, 1909). 

Alcohol recommended as a final ap¬ 
plication in all cases of wounds, dress- 



ALCOHOL (SAJOUS). 


507 


ing with either plain or carbolized 
gauze. In bruises and sprains equal 
parts of extract of witchhazel and al¬ 
cohol, applied as hot as can be borne, 
gives much better results than liniments 
or any of the clay and glycerin mix¬ 
tures, and is much more agreeable to 
the patient. In burns and scalds, with 
suppuration, alcohol is an ideal applica¬ 
tion, and where carbolic acid is in¬ 
dicated it can be used in any strength 
if followed immediately with alcohol. 
This also applies to suppuration in all 
kinds of wounds. In patients confined 
to bed for any length of time, the use 
of alcohol after bathing prevents bed¬ 
sores. Alcohol is one of the best anti¬ 
septics to clean instruments outside of 
an operating room. The hypodermic 
needle will always be ready if kept in 
alcohol, and there will be no need of 
inserting wires in it. It is best not to 
use a weaker solution than 60 per cent, 
of alcohol. Care is required, however, 
to get pure alcohol, as so many inferior 
brands are offered, which, if used, give 
disappointing results. S. S. Royster 
(Intern. Jour, of Surg., Oct., 1909). 

Reports concerning the therapeutic 
uses of alcohol in dermatology have 
recently been reviewed by Bulkley. In 
eczema Unna recommends an alcohol 
dressing having the following composi¬ 
tion: Sodium stearate, 6 parts; glyc¬ 
erin, 2.5; alcohol, to make 100. This 
has the advantage of greater perma¬ 
nency of effect than the rapidly evapo¬ 
rating pure alcohol, can be employed 
where the application of a bandage is im¬ 
practicable, is non-irritating and strongly 
bactericidal. In herpes simplex as 
well as herpes zoster, the virtues of 
alcohol, applied on cotton and re¬ 
newed at frequent intervals, were 
pointed out by Leloir and Dupas; if 
it be applied in the stage of erythema 
the eruption will disappear in a few 
hours; if in the vesicular stage, in 
the course of a few days. Leloir 
recommends that a small quantity of 


phenol be added, in order to alleviate 
further the burning and pain. In 
lupus erythematosus, striking results 
were obtained by Hebra, Jr., and by 
Kohn from the frequent application 
of alcohol,—40 to 50 times daily. 
Continued applications of alcohol led 
to cure in a case of favus reported by 
Canboni. In acne rosacea, Abrahams 
has given subcutaneous injections of 
20 to 30 drops of 95 per cent, alcohol, 
repeated at most three times a week, 
and found that, after a temporary 
local anemia, the injections produced 
a hyperemia lasting for some hours, 
by which obliteration of the dilated 
vessels could be secured, providing 
the treatment be kept up for two or 
three months. 

In frost-bite, insect-bites, and itch¬ 
ing conditions in general the local 
anesthetic property of alcohol comes 
into play. According bo Lauder 
Brunton, the itching in pruritus ani 
can be checked with absolute alcohol. 

In sprains and contusions a rubefa¬ 
cient as well as a cooling effect is 
exerted. 

In fever the body temperature may 
be lowered by bathing the surface with 
alcohol, diluted with 2 parts of water. 

Applied to aphthae or sluggish 
ulcers of various kinds, alcohol, undi¬ 
luted, acts as a stimulant to the proc¬ 
esses of repair. 

Used hot in a 10 to 20 per cent, solu¬ 
tion, alcohol has long been used as a 
gargle in tonsillitis and pharyngitis. 

In the prophylaxis of bed-sores and 
of cracked nipples, dilute alcohol is 
very effective when systematically 
rubbed over the areas exposed, hard¬ 
ening the skin so that it is rendered 
more resistant bo external influences, 
and bringing an increased amount 
of bipod to it, thus antagonizing 


508 


ALCOHOL (SAJOUS). 


local necrosis. Where the nipples 
are already the seat of fissures or 
excoriations, alcohol will not only 
tend to relieve discomfort by obtunding 
the sensory nerve-endings, but will 
harden the surrounding healthy skin 
and, by coagulating the albumin in the 
secretions of the raw surfaces, cover 
these areas with a thin, protective film. 
The same astringent property of alcohol 
is of value in the treatment of hyperi- 
drosis (excessive sweating) and ten¬ 
der feet. , 

As a hemostatic, alcohol is of some 
value in minor hemorrhages, espe¬ 
cially, where tiherq is merely an ooz¬ 
ing of blood from ruptured capillaries. 

As a solvent of fatty substances, and 
likewise as a bactericidal agent, alcohol 
is of value when applied to the hands 
and operative area previous to minor 
surgical procedures. The removal of 
fatty material from the skin surface 
facilitates the action of germicides, such 
as mercury bichloride, subsequently ap¬ 
plied. According to von Bruns, the 
value of alcohol in the preparation of 
the skin before operations is due not 
alone to its solvent and germicidal prop¬ 
erties, but also to the fact that it hardens 
the skin and thereby keeps the deeply 
lodged bacteria from coming to its sur¬ 
face. That this factor in the action of 
alcohol is not in reality of great mo¬ 
ment, however, would seem to be sug¬ 
gested by the recent experimental work 
of Ritchie, which tends to minimize the 
importance of the sweat-glands and 
hair-follicles of the normal skin as 
restive places for bacteria. 

Advantages of skin disinfection with 
alcohol pointed out. If the skin is 
bathed and shaved, then rubbed for five 
minutes with sterile gauze saturated 
with absolute alcohol, its disinfection is 
accomplished more perfectly than by 
any other physical or chemical method. 


Dehydrated alcohol or wood alcohol 
may be used instead of pure grain alco¬ 
hol in order to save expense. For 
effectiveness it is essential that the alco¬ 
hol used be nearly or quite absolute 
alcohol. Meissner (Beitrage z. klin. 
Chir., S. 198, 1909). 

Experiments with von Herff’s method 
of disinfecting the hands with acetone 
alcohol. It is thought that the com¬ 
bination of acetone enables the mixture 
to be used on all portions of the body, 
and attacks the fatty tissue and disin¬ 
fects it more thoroughly than alcohol 
alone. The use of the nailbrush may 
be omitted, and a longer disinfection is 
obtained by this method. The use of 
soda solution for ten minutes increases 
the efficiency of the method somewhat. 
As the method is a simple one, it is 
especially adapted for the use of nurses 
and midwives. In the clinic the alcohol 
employed was 95 per cent., and the pro¬ 
portion of acetone, after some experi¬ 
ment, was fixed at 10 per cent. The 
most efficient combination, however, 
seemed to be that of 50 per cent, alco¬ 
hol and 50 per cent, acetone. Pre¬ 
liminary cleansing with soap, water, and 
brush was omitted. Four minutes were 
occupied in disinfection. The method 
did not seem to irritate the skin, and 
one of the staff, who acquired eczema 
through other methods of disinfection, 
was much improved. Oeri (Zeit. f. Geb. 
u. Gyn., Bd. Ixiii, Hft. 3, 1908). 

Two years’ experience has demon¬ 
strated to the author’s satisfaction the 
superiority of this simple and con¬ 
venient method over all other techniques 
in which soap and water are permitted. 
He rubs the field of operation for five 
minutes with the 10 per cent, alcohol 
acetone solution and then applies a var¬ 
nish, the formula for which is 10 parts 
each of benzoin and dammar resin in 
100 parts ether, stained with 20 per 
cent, of an alcohol iodoiodide solu¬ 
tion (7 parts iodine, 5 parts potas¬ 
sium iodide and 100 parts alcohol). 
Von Herff (Therap. der Gegenwart 
Dec., 1909). 

Comparative tests of various methods 
of sterilization performed. A 5 per 
cent, alcohol solution of tannin sur- 


ALCOHOL (SAJOUS). 


509 


passes all the other techniques with the 
exception of tincture of iodine; it 
ranks with this, while it is free from its 
disadvantages. The tannin solution is 
applied to the hands for two minutes 
and to the field of operation for one 
minute; the previous use of water does 
not affect it. Zabludowski (Deut. med. 
Woch., March 2, 1911). 

A bacteriological and histological 
study of the action of alcohol on 
hands previously infected with bac¬ 
terial cultures, showed that after 10 
minutes’ contact of the hands with 
alcohol, scrapings from the epidermis 
and material obtained beneath the 
finger nails yielded no bacterial 
growth on bouillon in 15 trials; on 
gelatin the results were negative 25 
times, and positive 5 times. Other 
experiments showed that 10 minutes 
is the proper time to keep the hands 
in contact with alcohol for surgical 
disinfection; that the greater the 
concentration of alcohol used, the 
more complete the disinfection; that 
hands disinfected with alcohol, dried, 
and kept covered with a sterile com¬ 
press, remain sterile for at least 15 
minutes, while if kept immersed in 
sterile water they remain sterile for 
20 minutes. Marquis (Revue de 
Chir., Mar., 1912). 

The writer tested alcohol as a dis¬ 
infectant and insecticide, and found 
that, when used instead of solution of 
formaldehyde and in quantities of 4 
or 5 times larger, germs were killed 
as effectually. He found alcohol of 
70 or 80 per cent, strength best 
adapted for the purpose. The germs 
used in the tests were cholera vib¬ 
rios, typhoid and colon bacilli and^ 
staphylococci, all on silk threads. 
They succumbed with alcohol fumes 
exactly as in parallel tests with solu¬ 
tion of formaldehyde. Arkhipiants 
(Russky Vratch, xvi, No. 2, 1917). 

In a study of alcohol sterilization, 
the writer found that alcohol makes 
its way rapidly into the cells when 
the superficial tension of about 0.4 
is reached. Once inside the cells, it 
combines with the salt present in the 
bacteria and induces an irreversible 


precipitation of the protoplasm which 
signifies the death of the bacterium. 
Higher concentrations of alcohol do 
not have this effect but merely suck 
the water out of the protoplasm, 
which dries up the bacteria, but they 
are very resistant to drying. The 
power of alcohols to penetrate the 
thin layer of grease on the skin 
parallels their bactericidal power, as 
both are the effect of the same cause, 
namely, a low superficial tension and 
high solvent power for water and 
lipoids. And of all the alcohols, 
propyl alcohol is the most efficient. 
J. Christiansen (Hospitalstidende, 
Jan. 17, 1918). 

Finally, the value of alcohol as a pre¬ 
ventive and curative agent in carbolic 
acid burns is well recognized. The 
phenol is dissolved by the alcohol. 

Internally, there are but five indica¬ 
tions for alcohol that justify Its use 
under our present knowledge: (1) As 
an antidote to carbolic acid—only 
when it can be administered shortly 
—within one or one and a half hours 
—following the poison. Life saved 
in two instances by this measure. 
Diluted alcohol (50 per cent.) is 
better than brandy and whisky. (2) 
As a fuel, in fevers, exhausted states 
of the body, and marasmus of infants. 
Here our purpose must be to give 
only a quantity that the patient can 
metabolize or oxidize and derive 
therefrom energy. When we can 
detect alcohol on the breath, the 
dose must be decreased. An average 
dose of alcohol for this purpose is 2 
to 4 c.c. (4 to 8 c.c. whisky; 30 c.c. 
or less of wine, according to variety; 
10 to 30 c.c. of any of the “medicinal” 
proprietary foods), given every four to 
six hours, with or following other food, 
preferably. (3) For the chill of fe¬ 
brile stages—such as pneumonia, ma¬ 
laria, septicemia—here alcohol in 
medicinal dose {e.g., 15 c.c. or more 
of whisky) opens the surface capil¬ 
laries that are contracted in chill and 
so gives a sense of warmth to the 
patient, lowers the fever, and through 
cerebral depression blunts the pa- 


510 


ALCOHOL (SAJOUS). 


tient’s mental anguish. Of course, 
the chill of hemorrhage, shock, or 
other condition not accompanied 
• with fever contraindicates alcohol, (4) 
To reduce fever. In some cases of 
typhoid, where the plunge or sponge 
bath fails to lower an excessive tem¬ 
perature, 30 c.c. of brandy immediately 
preceding the bath will insure a notable 
reduction, by driving the warm blood to 
the surface to be returned cooled to the 
internal organs. In the presence of a 
low arterial tension or a very weak 
heart muscle, however, this use of alco¬ 
hol would hardly be justified. (5) As 
a narcotic, in many persons of ad¬ 
vanced years and a few with earlier 
arteriosclerosis who are apt to suffer 
from insomnia, a “night-cap” of 
brandy in the form of a “sling” will 
act favorably and is free from the 
unpleasant symptoms that often fol¬ 
low the use of the old or new hyp¬ 
notics. Fear of habit, in this in¬ 
stance, need hardly be considered. 
Prescribing alcohol to enable a pa¬ 
tient to withstand the strain of 
having a tooth extracted, an abscess 
opened, or wound sutured, on the other 
hand, is crude therapeutics. William 
Brady (N. Y. Med. Jour., Apr. 24, 1909). 

Alcohol Injections.—Neuralgia and 
Neuritis.—Injections of alcohol into 
or in the vicinity of nerve trunks for 
the purpose of relieving pain are em¬ 
ployed particularly in trifacial neural¬ 
gia (tic douloureux) and in sciatica, 
but have also been utilized in intract¬ 
able neuralgias of other nerves, in 
neuritis following influenza, in bleph¬ 
arospasm, and recently in laryngeal 
tuberculosis. 

The Schlosser plan of injection in tic 
douloureux, viz., the injection of alco¬ 
hol into the second or third divisions of 
the trifacial nerve at their emergence 
from the cranium, has been extensively 
tested and, owing to the prompt benefit 
it affords, is growing in favor, though 
it cannot be considered as a uniformly 
curative measure, a certain number of 


cases relapsing after a variable number 
of months of freedom from pain. The 
mode of action of the alcohol in these 
cases was elucidated in 1910 by Schlos¬ 
ser, who found through animal experi¬ 
mentation that alcohol of 70 to 80 per 
cent, concentration, when brought in re¬ 
lation with a nerve, caused degenerative 
processes to take place in all the ele¬ 
ments of the nerve except the neu¬ 
rilemma. Leszynsky, reporting 15 
cases of tic douloureux successfully 
treated by alcohol injection, stated his 
belief that this method is practically 
equivalent to a section of the nerve, 
with the added advantage of absence of 
an operative scar. The method is not 
applicable, however, to neuralgia of the 
first division of the trifacial, a certain 
amount of danger having been found to 
attend injections of this branch. 

Alcohol injections given in 75 cases 
of unmistakable tic douloureux, in¬ 
variably with relief. Thirty-six pa¬ 
tients were between 60 and 70 years of 
age, 13 between 70 and 80 years, and 1 
over 80 years. Patrick (Jour. Amer. 
Med. Assoc., Dec. 11, 1909). 

Benzyl Alcohol Injections.—This 
product, available in the shops under 
the name of phenmethylol, was intro¬ 
duced by Macht, in 1918, as a safe and 
efficient local anesthetic, acting on sen¬ 
sory nerves and on nerve conduction. 
It is used in 1, 2, and 4 per cent, solu¬ 
tions hypodermically. It is said to be 
^ery efficient, though comparatively 
free of untoward after-effects. 

Clinical and experimental studies 
showed that benzyl alcohol is an effi¬ 
cient local anesthetic when adminis¬ 
tered in aqueous solution. It is solu¬ 
ble up to 4 per cent, in water in 
physiologic saline. Its low toxicity 
as compared with that of commonly 
employed alkaloids such as cocaine; 
the ability of the organism to metab¬ 
olize it and excrete it in an innocu- 


ALCOHOL (SAJOUS). 


511 


ous form; its high boiling point and 
the consequent ease of sterilization; 
the comparatively low price of the 
drug and the ease of its production 
are its salient advantages. D. 1. Macht 
(Jour. Pharm. and Exper. Therap., 
Apr., 1918). 

Laryngeal Tuberculosis.—Alcohol 
injections into the superior laryngeal 
nerve for the relief of dysphagia in 
tuberculosis of the larynx were intro¬ 
duced by Hoffman, of Munich. Recent 
experiences with this procedure have 
only served to confirm and establish 
its usefulness as a palliative measure. 
Fishberg has employed the procedure 
in many cases and obtained relief for 
the patient in about 50 per cent. 

Alcohol injections into superior 
laryngeal nerve employed in a series 
of cases with gratifying results. The 
duration of the relief experienced is 
the striking feature of this method of 
treatment. The solution employed 
consists of 2 grains of hydrochloride 
of betaeucaine in an ounce of 80 per 
cent, alcohol. The patient being 
placed horizontally, the sound side ot 
the larynx is pressed toward the mid¬ 
dle line with the thumb of the left 
hand so that the affected half projects 
distinctly; the other fingers of the 
hand lie on this half. The index fin¬ 
ger enters the space between the thy¬ 
roid cartilage and the hyoid bone 
from without until the patient an¬ 
nounces that a painful spot has been 
reached. The nail of the index finger 
is now placed upon the skin in such 
a way that the point of entrance for 
the needle lies opposite its middle. 
The needle is pushed in for about 1.5 
cm.; this distance is marked off on 
the needle perpendicularly to the sur¬ 
face of the body. According to the 
thinness of the subcutaneous layer of 
fat, the perforation has to be more 
or less deep. The needle is then care¬ 
fully moved so as to seek a spot at 
which the patient feels pain in the 
ear. The syringe, filled with the al¬ 
cohol, warmed to a temperature of 


45° C. (113° F.), is screwed to the 
needle and the piston slowly pressed 
down. The patient now feels pain in 
the ear, the passing off of which he 
indicates by raising his hand. During 
the operation swallowing and speak¬ 
ing must be avoided. The injection 
is kept up until no further pain oc¬ 
curs in the ear. Then the needle is 
removed and collodion applied. The 
point of the needle is bevelled much 
more obtusely than the ordinary 
hypodermic needle, to avoid the dan¬ 
ger of puncturing a vessel. Dundas 
Grant (Lancet, June 25, 1910). 

Tumors.—Carcinoma of the uterus 
was treated with alcohol as long ago as 
1879 by Hasse, who made injections 
into the circumference of the tumors 
in 3 cases with good results; after 
twenty-three years the patients were 
alive and well. Obliteration of the 
blood-vessels and shrinkage of the 
tumor were found to have taken 
place, through connective-tissue pro¬ 
liferation around the growth. A sim¬ 
ilar plan of treatment has also been 
utilized in cancer of the breast. 

As a palliative measure, interstitial 
injections of alcohol were used by 
Vulliet, of Geneva, in inoperable cases 
of uterine cancer. The benefit ob¬ 
tained was ascribed by him to the 
local ischemia induced. 

ALCOHOLISM, OR ALCOHOL 
INEBRIETY.—D EFINITION.— 
Alcoholism is frequently defined as 
the result, in the organism, of excessive 
consumption of alcohol. The term, thus 
interpreted, should refer only to indi¬ 
viduals profoundly poisoned and dis¬ 
eased from this specific cause. Mod¬ 
ern research has shown, however, that 
there exists a large class of cases in 
which the excessive use of alcohol is 
a predominant feature, but which are 
not accurately described by the term 
‘‘alcoholism,” viz., those in which the 


512 


ALCOHOL (SAJOUS). 


use of spirits is only symptomatic of a 
neurosis of different nature and causa¬ 
tion. It is probable that at least 50 per 
cent, of all so-called alcoholics have 
suffered from disease of the nervous 
system before acquiring the alcoholic 
habit. 

Inebriety, meaning a poisoned or 
stuporous state directly or indirectly 
the result of alcohol, is, in reality, a 
more general term than “alcoholism,” 
since it refers to the condition of all 
those who use alcohol to excess. This 
term is also employed, however, to des¬ 
ignate toxic states resulting from the 
use of various other drugs, such as 
opium, cocaine, chloral, chloroform, 
etc. 

TOXICITY OF THE ALCO¬ 
HOLS. —All alcohols are poisonous, 
though their toxic power varies, con¬ 
siderably in accordance with the va¬ 
riety of alcohol ingested. Thus, the 
heavier members of the series (pro¬ 
pyl, butyl, and amyl alcohols), which 
have a higher boiling point than ordi¬ 
nary ethyl alcohol, are more toxic 
than the latter. Methyl alcohol, 
though the lightest of all the alco¬ 
hols, is, nevertheless, more poisonous 
than ethyl, forming an exception to 
the general rule that the toxicity of 
the alcohols rises with the increase 
in their molecular weights. The 
toxic action of methyl alcohol, or “wood 
spirits,” will be described later (v. 
Methyl Alcohol, Vol. VI). That of ethyl 
alcohol, which forms the subject of this 
article, is modified, to a certain extent, 
by the nature of the preparaton con¬ 
taining it. Spirits exert a more rapid 
toxic effect than wines or beers, owing 
to the greater concentration and quan¬ 
tity of alcohol present in the former. 
The different kinds of spirits them¬ 
selves exhibit differences in toxicity in 


accordance with the material from 
which they are produced, the variations 
being due to differences in the amount 
of certain additional toxic compounds 
contained, such as aldehyde, ketones, 
furfurol, ethers, etc. Thus, according 
to Dujardin-Beaumetz and Audige, 
spirits made from wine (brandy) are 
the least toxic; next follow in or¬ 
der spirits made from perry, cider, 
grain, beets, and molasses; finally 
come spirits made from potatoes and 
sorghum, which are the most toxic, 
owing to the relatively large pro¬ 
portions of isobutylic and amylic al¬ 
cohols they contain. Spirits of in¬ 
ferior grade are especially dangerous 
because they are made with impure 
alcohol, the disagreeable taste and 
odor of the impurities being masked 
by admixture of artificial flavors and 
essences (Pouchet). In addition to the 
true spirituous liquors already referred 
to, there is a large group of liquors 
representing a solution of various aro¬ 
matic principles, either of vegetable 
origin or produced synthetically, in a 
menstruum of alcohol. Here the ef¬ 
fects of the aromatic principles are 
added to those of alcohol, and these 
fluids may, therefore, be divided into 
two groups, according as the tendency 
of the aromatic principle contained is 
to produce epileptiform convulsions 
(best illustrated in the case of ab¬ 
sinthe), or to bring on stupor (anise, 
mint, angelica, etc.). 

The fatal dose of alcohol varies 
within wide limits. The factors influ¬ 
encing it include not only the individ¬ 
ual’s habits with respect to alcoholic 
indulgence, but in addition his state 
of health, the climate and tempera¬ 
ture, and the rapidity of absorption 
(Pouchet). The average lethal dose 
has been stated to be 60 to 180 Gm. 


ALCOHOL (SAJOUS). 


513 


(2 to 6 ounces, approximately). Less 
than 1 pint of whisky has sufficed to 
cause the death of an adult. In the 
lower animals, Lussana and Albertoni 
give 6 Gm. (1% drams) per kg. of 
body weight as the minimum lethal 
dose. 

VARIETIE S. —There are two 
forms of alcoholism: (1) the acute, in 
which alcoholic poisoning is speedily 
manifested in active excitement and 
disturbance, or iu which a sudden ex¬ 
acerbation of the disorders attending 
the chronic type gives rise to a corre¬ 
spondingly marked symptomatic activ¬ 
ity; (2) the chronic, in which the 
continued ingestion of alcoholic bever¬ 
ages in more or less considerable 
amounts sets up gradually progressing 
pathological changes in the various 
organs and tissues, thereby giving rise 
to chronic disorders of each of the 
parts thus affected. 

Under acute alcoholism are to be 
considered not only acute alcoholic 
poisoning, intoxication, or “drunken¬ 
ness,” but also acute alcoholic epilepsy, 
acute alcoholic hysteria, acute alcoholic 
delirium or delirium tremens, and acute 
alcoholic mania or mania a potu. 

ACUTE ALCOHOLISM. 

DEFINITION. — A condition re¬ 
sulting from the ingestion, within a 
short period, of alcohol in sufficient 
quantity to produce exaggerated 
physiological effects or actual poison¬ 
ous effects. The amount required 
to intoxicate varies widely according 
to the natural susceptibility of the in¬ 
dividual, and to whether or not his 
organism has become accustomed to 
the action of alcohol through re¬ 
peated use. 

After long-continued over-indul¬ 
gence in alcohol (7 to 10 years) an 
individual develops delirium tremens. 

1 - 


The disease usually manifests itself 
in three stages—the incipient form, 
the fully developed classical form, 
and the comatose form (wet brain). 
The writers, who see about 2500 
cases of alcoholism every year, find 
that about 10 to. 15 per cent, of the 
cases of delirium tremens pass into 
the comatose form. The transition 
from delirium to cerebral edema is 
fairly well marked. The semi-coma 
which succeeds the active delirium is 
striking, and the delirium now be¬ 
comes the low muttering type. The 
symptoms of wet brain are essen¬ 
tially meningeal—semi-coma, gen¬ 
eralized hyperesthesia, and muscular 
rigidity (Kernig’s sign and neck 
rigidity) standing out prominently; 
the more marked are the latter two 
features the graver is the prognosis. 
The cerebrospinal fluid is to all ap¬ 
pearances normal. The mortality is 
nearly 75 per cent. Sceleth and Bie- 
feld (Amer. Jour. Med. Sci., June, 
1915). 

SYMPTOMS. —Three stages are 
discernible in this condition: The first 
is that of beginning vascular relaxation 
and primary excitation. The intoxi¬ 
cated individual is usually lively, merry, 
agile, and joyous; all excitement and 
energy; in the highest spirits, cheerful, 
hopeful, and communicative; mercurial 
and confiding, often telling of his pri¬ 
vate affairs to strangers. There is a 
warm glow on his countenance, and he 
appears at his best. Gradually his spir¬ 
its rise still higher; he becomes more 
demonstrative in love or in argument, 
more emphatic in his gestures, more 
furious in his fun, and very much 
louder in his laughter as the second 
stage is ushered in. With this he be¬ 
comes much less reasonable and amen¬ 
able, incoherence of thought and speech 
gradually sets in, the imagination rev¬ 
els, exaggeration is a prominent fea¬ 
ture, and the emotions dominate the 
subject, intellect, reason, will, and con- 

■33 


514 


ALCOHOL (SAJOUS). 


science rapidly fading into the back¬ 
ground. In some cases his thoughts, 
speech, and actions are exaggerated. In 
other instances they are transformed, 
the habitually modest, retiring man be¬ 
coming a boaster and a braggart, the 
truthful a liar, the meek violent. With 
all this, the speech thickens, the lower 
and then the upper limbs cease to act 
in unison; the intoxicated cannot 
stand, but staggers with a paralytic un¬ 
steadiness, the muscles becoming flabby 
and feeble. The third stage, that of 
“dead drunkenness,” reveals the sub¬ 
ject unconscious, with the pallor of ap¬ 
parent death on the face, extreme cold¬ 
ness of the skin, accompanied by total 
insensibility, and an utter disregard of 
the “world without.” Sensation, per¬ 
ception, volition, and emotion, all are 
absent. Through this living death there 
lingers in the heart the only spark of 
vitality that keeps the unconscious 
drunkard alive, till the faculties have 
emerged—if, indeed, they do emerge— 
from the depth of narcotism into which 
they were plunged. The first, pleasur¬ 
able stage, and the second stage, less 
pleasant, may vary in intensity and du¬ 
ration, but the third stage, that of 
insensibility, usually lasts from six to 
twelve hours (Norman Kerr). 

In the first stage, that of exhilaration 
or apparent stimulation, there is an in¬ 
crease of the heart-rate, and frequently 
a rise in the blood-pressure. The 
breathing is generally hastened and be¬ 
comes deeper. The skin is reddened, 
and the surface temperature rises 
slightly, owing to the paralyzing effect 
of the alcohol on the superficial blood¬ 
vessels, through which an increased 
amount of warm blood, therefore, 
courses. The pupils are of normal size 
or slightly dilated, and the higher psy¬ 
chic processes—those involving contin¬ 


ued attention, reflection, judgment, self- 
control—gradually fall in abeyance. 

The manifestations of the second 
stage are similar to those of the first, 
but more pronounced and with the 
added presence of motor inco-ordina- 
tion, due to the effects of the drug on 
the cerebellar and spinal centers. A 
subjective feeling of intense peripheral 
warmth is experienced, the pulse is full 
and bounding, and the respiration hur¬ 
ried and frequently irregular. Inco¬ 
herence of speech and staggering gait 
are the most prominent symptoms of 
this stage, though the relative time re¬ 
quired for the appearance of each va¬ 
ries notably in different individuals, 
some getting drunk first “in the legs,” 
others “in the tongue.” Nausea and 
vomiting may also appear, and toward 
the close of the period facial pallor and 
a tendency to syncope may be present. 

In some instances the first and sec¬ 
ond stages, instead of showing the 
individual in a condition of general 
excitement, are characterized by de¬ 
pression of spirits, merging more or 
less insensibly into the ultimate stage 
of total cerebral inaction. In another 
group of cases, on the other hand, the 
initial excitement is unusually pro¬ 
nounced, the subject crying out loudly, 
experiencing illusions, and even com¬ 
mitting acts of violence. 

The third stage of alcoholic intoxi¬ 
cation, that of unconsciousness and 
deepening coma, is characterized by 
successive abolition of the functions of 
various portions of the central nervous 
system. The spinal cord and cranial 
nerve-centers becoming depressed, mo¬ 
tion and sensation are progressively 
lost. The subject cannot be awakened 
by shouting in the ear; his musculature, 
including the sphincters, is completely 
relaxed, and general sensibility is abol- 


ALCOHOL (SAJOUS). 


515 


ished. The pulse may be full and ap¬ 
proximately normal in rate, or may be 
feeble and slow. The breathing is 
slow, labored, and sometimes irregular 
—an indication of beginning paralysis 
of the medullary centers. It is also 
stertorous, owing to relaxation of the 
muscles of the soft palate. The skin 
is now pale and covered with cold 
sweat, though the face is bloated, the 
lips purplish and swollen, and the con- 
junctivae markedly congested. The tem¬ 
perature of the body is lowered, the 
rectal reading being invariably reduced' 
by 1, 2, or even 4° F. (Butler). The 
pupils may be dilated, especially in 
cases of severe intoxication, and the 
light-reflex abolished. The knee-jerks 
and other reflexes are likewise lost. 

In cases terminating fatally, death 
takes place from respiratory arrest 
after a period ranging from one-half 
hour to fifteen or twenty hours (Pou- 
chet). 

When an unusually large amount of 
alcohol has been taken—true cases of 
acute alcohol poisoning, as distin¬ 
guished from those of ordinary “intox¬ 
ication”—the stages of excitement are 
apt to be of very brief duration (es¬ 
pecially if the alcohol has been taken 
on an empty stomach), the subject sink¬ 
ing promptly into coma. Vomiting, 
swallowing movements, piercing cries, 
and muscular contractures betoken a 
brief primary excitation of the nerve- 
centers, after which depression quickly 
appears, indicated by respiratory and 
circulatory disturbances and general 
anesthesia. Convulsions and death 
from respiratory paralysis or edema of 
the lungs may finally result. 

Acute alcoholic intoxication in some 
instances brings forth phenomena for¬ 
eign to the conventional manifestations 
already described. Thus, in some cases, 


an epileptic attack is the most prom¬ 
inent result. It may occur either in an 
individual already subject to epilepsy, 
in which event the alcohol acts indi¬ 
rectly, being merely an exciting cause 
of the paroxysm; or, it may take place 
as a direct result of the effects of al¬ 
cohol, in persons previously not subject 
to epileptic seizures, under which 
circumstances the condition may be 
termed a true acute alcoholic epilepsy. 
Again, an outburst of acute mania may 
be the result of alcoholic intoxication. 
Such a result is seen most frequently 
in cases of incipient or fully developed 
general paralysis. Similarly imbeciles 
and epileptics are particularly likely to 
experience hallucinations under the in¬ 
fluence of alcohol, and to commit acts 
of violence upon the impulse of the 
moment (Pouchet). Finally, hysterical 
paroxysms may also result from the 
consumption of ’alcohol, even in rela¬ 
tively small amounts, and in individ¬ 
uals otherwise never hysterical (Kerr). 

DIFFERENTIAL DIAGNOSIS. 
—In the first two stages of acute 
alcoholic intoxication, those of excita¬ 
tion and of motor inco-ordination, the 
symptoms present are sometimes dis¬ 
tinguishable with difficulty from those 
produced by the ingestion of other 
drug excitants, such as opium, or from 
those of apoplexy, unless, as is fre¬ 
quently the case, a clue to the cause of 
the disturbance is furnished by the find¬ 
ing of alcohol on the premises, or a 
history of alcoholic indulgence can be 
obtained. In the case of apoplexy, 
however, the uncertainty is not likely 
to be of long duration, the symptoms 
of excitation soon passing off entirely, 
or being promptly replaced by coma. 

A more important and difficult dis¬ 
tinction is that to be made between the 
third stage of intoxication by alcohol, 


516 


ATXOHOL (SAJOUS). 


Differential Diagnosis of Acute Alcoholism. 



Acutb 

Alcoholism. 

Urkmic 

Coma. 

Apoplkxy. 

Concussion 
OF THE Brain. 

Opium 

Poisoning. 

Diabetic 

Coma. 

Consciousness. 

Not absolutely 
lost; can usu¬ 
ally be aroused 
by shouting or 
shaking. 

Completely 

lost. 

Partially or 
entirely lost. 

Rarely com¬ 
pletely lost. 

Profound stu¬ 
por. 

Completely 

lost. 

Tempera tuce. 

Often sub¬ 
normal. 

Variable; not 
uncommonly 
subnormal. 

Usually rises 
above normal. 

Subnormal. 

Often sub¬ 
normal. 

Subnormal. 

Pulse. 

Frequent; 
later weak. 


Slow, full, 
tense. 

Frequentand 
weak. 

Slow, full. 

Frequent. 

Respiration, 

Pupils. 

Stertorous. 

Usually di¬ 
lated; equal, 
and react to 
light. 

Often Cheyne- 
Stokes. 

Normal or 
dilated. 

Slow, sterto¬ 
rous, and puff¬ 
ing. 

Dilated or 
CO ntract ed; 
sometimes un¬ 
equal. 

Slow and shal¬ 
low. 

Usually di¬ 
lated ; equal, 
and react to 
light. 

Very slow. 

Contracted. 

Long-drawn 
inspiration, 
sighing expi¬ 
ration. 

Dilated. 

Skin. 

Pace flushed. 

Waxy pallor. 

Face flushed 
or cyanotic; 
sometim e s 
pale. 

Cold and pale. 

Face flushed, 
sometimes cy- 
anosed. 

Sometimes 

cyanosis. 

Reflexes. 

Sluggish or 
abolished. 


Lost on para¬ 
lyzed side and 
often on sound 
side. 

Sluggish or 
lost. 


Lost. 

Convulsions. 

Uncommon, 
except in dan¬ 
gerous cases. 

Common. 

Usually only 
at time of 
stroke. 

Late, if any. 

Uncommon. 

Rare. 

Paralyses. 

Odor. 

None. 

Alcoholic odor 
of breath. 

Rare. 

Urinous odor 
sometimes. 

Hemiplegia. 

None. 

Transient, if 
any. 

None. 

None. 

Laudanum 
odor on breath 
sometimes no¬ 
ticeable. 

None. 

Sweet odor 
of breath. 

Urln. 

Contains al¬ 
cohol; other¬ 
wise not char¬ 
acteristic. 

Contains al¬ 
bumin, casts, 
and decreased 
urea. 

Not charac¬ 
teristic. 

Not charac¬ 
teristic. 

Not charac¬ 
teristic. 

Glycosuria, 
acetonuria, di- 
aceturia. 

Emunctories. 

Frequently 
incontinence 
of urine and 
feces. 

Anuria com¬ 
mon. 


Retention of 
urine; incon¬ 
tinence of fe¬ 
ces. 

No involun¬ 
tary evacua¬ 
tions. 


Special signs. 


Edema of 
face and feet; 
albuminuric 
retinitis. 

Deviation of 
head and eyes 
to side oppo¬ 
site that of 
paralysis. 

Probably ev¬ 
idence of trau¬ 
ma to head. 




that of sleep and insensibility, and 
comatose conditions, such as uremia, 
apoplexy, concussion of the brain (in 
cases of fractured skull), acute opium 
or chloral poisoning, and diabetic coma. 
In police stations so-called “drunks” 
are often not such, and a fatal result 
may thus be practically insured. An 
alcoholic odor of the breath is, of 
course, characteristic of alcoholic 
intoxication, but it is not path¬ 
ognomonic ; an individual uncon¬ 


scious from another cause may, per¬ 
haps, have taken or been given 
alcohol in quantity insufficient to in¬ 
toxicate. 

Though, according to quite a number 
of observers, pressure on the supra¬ 
orbital nerves in their respective 
notches will elicit signs of life in the 
alcoholic when it would not in other 
states of unconsciousness, the fact 
remains that mistakes have been, and 
are still, frequently made in the dif- 


















517 


ALCOHOL (SAJOUS). 


ferential diagnosis between ordinary 
cases of “drunkenness’’ and cases of 
fractured skull. It may, indeed, in 
some instances be practically impos¬ 
sible, even for the medical expert, to 
form a correct opinion as to the caus¬ 
ative agent until time has been given 
for the disappearance of the alcoholic 
symptoms. 

To facilitate the recognition of the 
morbid condition that may be present, 
the chart (see p. 516) is presented. 

PATHOLOGY. —The most prom¬ 
inent of the post-mortem appearances 
in fatal cases of acute alcoholic poison¬ 
ing is cerebral congestion. While no 
noteworthy destructive lesions of the 
cerebral substance proper may be 
found, hemorrhagic, extravasations may 
quite frequently be discovered in the 
meninges at the base of the cerebellum, 
in the subarachnoid space, or even in 
the lateral ventricles (Pouchet). 

Marked congestion of the lungs and 
respiratory passages is also commonly 
a feature. The right heart cavities may 
be found distended with semifluid 
blood. Tardieu in one case discovered 
apoplectic extravasations of blood in 
the lungs. The gastrointestinal mucous 
membranes may also be markedly con¬ 
gested, though such a condition is, of 
course, in no sense peculiar to alcohol 
poisoning. In the case cited by Kerr, 
of a man found dead after a drinking 
bout, “the mucous membrane of the 
stomach was so inflamed and angry, 
with patches of a deeper hue extending 
over the pyloric surface to the duode¬ 
num, and a grumous, slightly muco¬ 
purulent exudation from bleeding 
points, that arsenical poisoning was sus¬ 
pected.” Hepatic congestion we would 
naturally expect to, and frequently do, 
find as a post-mortem evidence of 
acute alcohol poisoning. 


Dana studied the brain-cells in 10 
cases of acute alcoholism by the Nissl 
method of staining with methyl violet: 
(ci) patients who died of alcoholism 
with all the symptoms of meningitis 
showed congestion of the membranes 
(pia, arachnoid), with some edema in 
their texture; (b) microscopic exam¬ 
ination rarely showed any migration of 
leucocytes or anything approaching en¬ 
cephalitis; (f) the larger (pyramidal 
and giant) nerve-cells showed pigmen¬ 
tation to an intense degree, the pigment 
being dififused through the cell-body; 
(d) the cytoplasm showed various de¬ 
grees of degeneration (fatty and gran¬ 
ular) ; (c) the cell-body generally was 
shrunken, and the nucleus partially 
so; (/) pericellular nuclei had prolif¬ 
erated, and were freely present in the 
pericellular sacs. In cases where 
death was due to exhaustion the 
shrinkage of cells was marked. 

In examining the bodies of persons 
dying from delirium tremens, Le 
Count found alterations so regularly 
in the cortex of the adrenals that he 
was led to seek the reason for the 
changes. The changes consist in a 
more or less striking diminution of 
the yellow color of the normal cor¬ 
tex. In very marked instances a red¬ 
dish brown color is assumed, with 
only occasional irregularly distrib¬ 
uted areas of yellow, or there may 
seem to be entire absence of that 
color. The glands were removed, the 
fat dissected away and then fixed in 
a 10 per cent, dilution of liquor for- 
maldehydi, and after a few days the 
transverse segments were frozen and 
sectioned. As controls for this work, 
the adrenals from persons meeting 
sudden death were used and sections 
prepared the same way. The ad¬ 
renals from 34 persons dying from 
delirium tremens were compared 
with the controls, and in practically 
every instance the doubly refractive 
droplets in the delirium tremens ad- 


518 


ALCOHOL (SAJOUS). 


renals were diminished slightly, 
moderately, markedly, very markedly, 
and sometimes entirely absent in a 
given area. E. F. Hirsch (Jour. 
Amer. Med. Assoc., Dec. 19, 1914). 

The introduction of alcohol into 
the stomach greatly increases the 
catalase of the blood, while the in¬ 
troduction of alcohol directly into 
the vascular system decreases the 
catalase of the blood. The latter 
morbid effect is due to the destruc¬ 
tion, of the catalase by the alcohol. 
Burge (Amer. Jour, of Physiol., Dec., 
1917). 

TREATMENT. — In common 
drunkenness, where the pallor and 
depression are not too marked, and 
where the respiration is active and 
the pulse is good, the patient may be 
allowed to sleep. The elimination 
of the poison occurring rapidly, he 
awakes after several hours with more 
or less headache, depression, irrita¬ 
bility of the stomach, and tremor as 
results of the intoxication. Light and 
easily digested food, Vichy and milk 
as beverages, and a light aperient, if 
required, will soon be followed by 
recovery. Ammonium carbonate, 1 
dram (4 Gm.) in a glassful of water, 
will counteract depression. Alcohol 
for the latter purpose should never be 
given. 

In severe cases in which there is 
a tendency to coma, with shallow 
breathing and feeble pulse, the prob¬ 
ability that a quantity of alcohol is 
still present in the stomach should be 
borne in mind. The stomach should 
be emptied by means of the stomach 
tube and washed out with warm 
water. External heat should be ap¬ 
plied, especially to the abdomen and 
feet, and the patient placed in a warm 
room. Depressing emetics are con¬ 
traindicated, since the depression is 
already excessive and the dangerous 


feature. No alcohol should be admin¬ 
istered as a stimulant. Hypodermic 
injections of strychnine, atropine, or 
digitalis are of great value to restore 
the equilibrium of the circulation. 

In acute alcoholism attended by 
excitement and perhaps convulsions, 
especially in robust patients, free 
emesis should be procured promptly 
by giving grain (0.006 Gm.) of 
apomorphine hydrochloride. This 
usually causes vomiting in four or 
five minutes, and is then followed by 
relaxation and sleep. Digitalis or 
digitalin has also been recommended 
in this class of cases to counteract 
the morbid effects of the poison on 
the heart and circulation, and thus 
restore the patient to his normal con¬ 
dition much sooner. Hot (105° F.) 
rectal enemata of saline solution are 
also valuable in these cases during 
the acute attack to reduce the tox¬ 
icity of the blood, if the enema is 
retained long enough to insure ab¬ 
sorption. Hypodermoclysis should be 
resorted to if the rectal injections do 
not prove satisfactory. 

As sedatives paraldehyde or amy- 
lene hydrate is often used with advan¬ 
tage. Veronal has been found espe¬ 
cially effective by Von der Porten in 
15-grain (1 Gm.) doses repeated in 3 
then 5 hours until sleep is produced. 

The value of apomorphine hydro¬ 
chloride in acute alcoholism was 
pointed out by C. J. Douglas, of Bos¬ 
ton, in 1899, but remains almost un¬ 
known. The drug acts promptly 
when administered as an emetic in 
doses of Ho or % grain, and it acts 
with almost equal promptness when 
administered as an hypnotic. The 
alcoholic, however wild or noisy, will, 
as a rule, be peacefully sleeping in 
ten or twelve minutes after Ho to Ho 
grain is administered subcutaneously. 
This sleep may last several hours. 


ALCOHOL (SAJOUS). 


519 


when the patient awakens refreshed 
and sober. Douglas employed the 
remedy, with these doses, in over 
200 cases, mostly alcoholics, including 
cases of delirium tremens, and with 
gratifying results. Drs. Coleman and 
Polk, of Bellevue Hospital, New 
York, used it in over 300 cases of 
alcoholism; also with gratifying re¬ 
sults. Dr. Rosenwasser, inebriatist to 
Newark Dispensary, Newark, N. J., 
has also used apomorphine in the 
same manner, and for the same pur¬ 
pose, and with equally satisfactory re¬ 
sults. The dose administered was 
from Yso to Yzo grain. With these 
doses, the hypnotic effect is secured 
in 67 per cent, of the cases. Even 
Yao grain, in the author’s experience, 
is effective with some patients. A. M. 
Rosebrugh (Can. Jour. Med. and 
Surg., Oct., 1908). 

Apomorphine is of great value in 
acute alcoholism. The desire for 
liquor in these cases becomes im¬ 
peratively dominant. Apomorphine 
enforces sleep, and when the patient 
awakens his chain of thought has 
been broken and the attack is over 
in many cases. In all such cases the 
action of an emetic is of some value 
in sobering the patient and diminish¬ 
ing or abolishing the desire for more 
drink, and, therefore, the dose usually 
given is Yio grain by hypodermic in¬ 
jection, adding Yzo grain strychnine 
if the heart is acting poorly. When¬ 
ever possible when given the injec¬ 
tion the patient should be lying in 
bed, and basins should be in readi¬ 
ness, as the action of the drug is 
rapid. The author has always been 
able to secure the hypnotic effect. In 
many cases grain given hypo¬ 
dermically,will be found sufficient to 
induce sleep. If the general condition 
of the patient is fair the dose may 
safely be repeated in about three 
hours, if necessary, as the drug is not 
cumulative in its action. C. A. Rosen¬ 
wasser (Med. Times, Dec., 1910). 

The injection of magnesium sul¬ 
phate with the aid of lumbar puncture 
is also recommended. 


The writer withdraws cerebro¬ 
spinal fluid by lumbar puncture, in 
amounts as large as possible—50 to 
60 c.c. An equal amount of sterile 
1 per cent, sodium bromide solution 
is then injected with a syringe. Im¬ 
mediate improvement in delirium 
usually occurs, followed by tem¬ 
porary return and then permanent 
disappearance of delirium. Relapse 
occasionally after a few days is usu¬ 
ally controlled by repetition of the 
injection. S. P. Kramer (Boston 
Med. and Surg. Jour., Oct. 30, 1913). 

In using magnesium sulphate, lum¬ 
bar puncture should be performed 
and 10 to 40 c.c. (2 Mj to 10 drams) 
of spinal fluid vy^ithdrawn. Then 1 
c.c (16 minims) of a 25 per cent, 
solution of magnesium sulphate is 
injected for each 25 pounds of body 
weight. The withdrawal and injection 
should be made with the patient in 
the sitting posture and he should 
then be lowered to one of semi¬ 
recumbency. Constant attention is 
required for 24 hours after the injec¬ 
tion to secure nourishment and 
proper care of the bladder and rec¬ 
tum. The treatment produces prompt 
relaxation, E. A. Leonard (Jour. 
Amer. Med. Assoc., Aug. 12, 1916). 

A study of 76 cases in the St. Louis 
City Hospital, in 34 of which the only 
treatment was a lumbar puncture, 
and in the other 42 treatment was by 
magnesium sulphate, paraldehyde, and 
bromides, with digitalis if the pulse 
was rapid. The cases treated by sim¬ 
ple lumbar puncture without medica¬ 
tion remained in the hospital on the 
average 3 days, the same as the oth¬ 
ers, but they left virtually recovered, 
whereas those treated otherwise left 
in shaky, nervous condition. The 
average amount of fluid withdrawn 
was 28 c.c. with a maximum of 50 and 
a minimum of 10 c.c.; the average 
pressure was 109 (water) with a 
maximum of 220 and a minimum of 
65. The iodoform test revealed 
the presence of alcohol with cer¬ 
tainty in 30 of the 34 cases; it was 
questionably present in 3, and ab¬ 
sent in 1. The Nonne-Apelt and 


520 


ALCOHOL (SAJOUS). 


Noguchi tests were positive in 29 
of the 34 cases. Barnes and Hein 
(Jour. Mo. State Med. Assoc., Nov., 
1917). 

The following is the routine treat¬ 
ment for delirium tremens: Cathar¬ 
sis by means of calomel followed by 
a rather large dose of Epsom salts, 
because of the effect of sulphate of 
magnesium in dehydrating the tis¬ 
sues of the body. Ten drops of tinc¬ 
ture of digitalis and of nux vomica 
by mouth every 3 hours. In the 
active stage of delirium strychnine 
and digitaline are given hypoder¬ 
mically. This stimulation the writer 
believes to be perhaps the most 
essential part of the treatment. In 
severe cases spinal puncture is re¬ 
sorted to as soon as the patient be¬ 
gins to have hallucinations. The 
cerebrospinal fluid is always under 
pressure and from 30 to 60 c.c. is 
usually withdrawn. This procedure 
is followed by a rapid reduction of 
the delirium, especially in cases 
which have had preliminary stimula¬ 
tion and alkalinization. If the 
delirium returns, spinal puncture is 
repeated, and the fluid is usually 
found to be again under pressure. 
If the delirium still continues in spite 
of the spinal puncture, or if the pa¬ 
tient is pale and covered with per¬ 
spiration with a low, muttering de¬ 
lirium, an intravenous injection of 
normal saline solution is given, or 
better, Fisher’s solution, H. H. 
Hoppe (Jour. Nerv. and Med. Dis., 
Feby., 1918). 

CHRONIC ALCOHOLISM. 

DEFINITION. —A condition re¬ 
sulting from the long-continued use 
of alcohol in excessive amounts. As 
was stated to be the case with acute 
alcoholism, the quantity of alcohol 
necessary to cause harmful results 
varies considerably in different per¬ 
sons. The manifestations of chronic 
alcoholism are varied. Many symp¬ 
toms due to toxemia and functional 
derangements closely simulating or¬ 


ganic changes are observed in the 
beginning. Later evidences appear 
of true organic disease, affecting one 
or more organs or systems of organs 
in individual cases. Thus the stom¬ 
ach, the nervous system, the circula¬ 
tory organs, the kidneys, the liver, 
are all common seats of special inva¬ 
sion. In many cases the symptoms 
are very complex, and are not such 
as lead to the discovery of any par¬ 
ticular organic lesion. As already 
stated, the alcoholism is itself some¬ 
times secondary to a neurosis of 
other nature, in which event complex¬ 
ity of symptoms is to be expected. 

Dipsomania signifies a condition, he¬ 
reditary in origin, in which uncon¬ 
trollable desire for alcohol is present 
at intervals only, the patient being 
free of alcoholic tendencies in the 
intervening periods. 

Delirium tremens is another special 
manifestation arising from the pro¬ 
longed effects of alcohol on the brain. 
It will be discussed later in a separate 
section of this article. 

SYMPTOMS. —Most cases will ex¬ 
hibit in the beginning deranged diges¬ 
tion, fermentation in the stomach and 
bowels, constipation or diarrhea, muf¬ 
fled heart-sounds, irregular action with 
high-tension pulse, and increased dull¬ 
ness over the liver, perhaps with 
tenderness in spots. There is very 
commonly trembling, the hands are un¬ 
steady in their movements, the reflexes 
are diminished or absent, and there are 
areas of extreme tenderness over the 
body, while numbness of the limbs, 
rheumatic pains in both the lower and 
upper extremities, congested conjunc- 
tivae and retinae, and defects of both 
sight and hearing are often present. 
The patient may complain of anorexia, 
insomnia, chills, and frequently talks 


ALCOHOL (SAJOLS). 


521 


about malaria as Ihe cause of his symp¬ 
toms. The urine is likely to he of high 
specific gravity, and to show albumin 
and an excess of phosphates. Chronic 
catarrhal conditions of the pharynx 
and larynx, dilatation of the skin ves¬ 
sels, sometimes pustular eruptions, are 
other early symptoms often seen. 

At a later period the symptoms are 
more likely to point to certain struc¬ 
tures of the body upon which the alco¬ 
hol has exerted its chief effect. They 
may be grouped as follows:— 

(1) Digestive System .—Chronic gas¬ 
tritis is a very frequent result of 
alcoholism. The patient complains of 
anorexia, nausea and vomiting, acute 
pain over the stomach, and constipa¬ 
tion. The breath is foul and the tongue 
coated. These symptoms, usually most 
marked in the morning, the subject 
finds to be best relieved by further use 
of alcohol. The relief is but temporary, 
however, and when it ends the diffi¬ 
culty is increased. 

Gastritis and achylia are the rule, 
but a number of factors combine to 
induce them, not only the liquor but 
the irregular meals and habits of life 
of persons addicted to alcohol. 
Achylia was pronounced in 50 per 
cent. When they enter the hospital 
and get regular food and rest, the 
stomach usually rapidly recuperates 
and, as the gastritis subsides, the 
achylia subsides with it. Determina¬ 
tion of the pepsin may be important 
for the prognosis, as the achylia did 
not retrogress in the few with apep- 
sia. The discovery of inadequate 
pepsin secretion therefore prophesies 
permanent achylia. Vogelius and 
Wiltrup (Hospitalstidende, Mar. 15, 
1916). 

Long-continued alcoholic intoxica¬ 
tion produces in some cases pronounced 
structural changes in the liver, most 
frequently cirrhosis, with contraction 
of the organ, or fatty infiltration, with 


increased size. The symptoms of the 
former are those of chronic catarrh of 
the stomach and intestines (anorexia, 
nausea, flatulence, constipation, some¬ 
times light-colored stools),—which is 
favored by the congestion caused in 
these organs through compression of 
the portal vessels,—together with 
others directly due to the same con¬ 
dition, such as hemorrhages from 
the lower esophagus, nose, pharynx, 
or even the stomach or intestines; 
hemorrhoids; distention of the veins 
of the face, especially the nose, or 
of other portions of the body, usually 
combined with flushing due to over¬ 
filled capillaries; occasionally jaun¬ 
dice. Later there may appear ascites, 
edema of the right pleura or of 
the lower extremities. Enlargement 
of the spleen is common late in the 
disease. Fatty infiltration of the liver 
produces no such distinctive symptoms, 
since there is no portal obstruction. 
The organ shows a moderate increase 
in size, but its functions are not mark¬ 
edly altered. 

Fahr reports a series of 309 autopsies 
performed at the Hafenkrankenhaus 
(harbor hospital) of Hamburg on vic¬ 
tims of chronic alcoholism dying from 
either alcoholism alone or from other 
causes, no less than 98 being suicides. 
In nearly all the cases the alcohol had 
been taken in the form of spirits, not 
as beer or wine. The results of these 
autopsies are distinctly not in harmony 
with the conception that alcohol is a 
poison which produces widespread and 
gross anatomic changes throughout the 
body, or that it is a common cause of 
either arteriosclerosis or nephritis. 
Even cirrhosis of the liver is far less 
common in alcoholics than it is usually 
supposed to be, for, of the 309 cases, 
in but 11 was cirrhosis the cause of 
death; in 2 other bodies there was an 
advanced cirrhosis, but death was due 
to some other cause. Of 100 cases of 
cirrhosis in which autopsies were per- 


522 


ALCOHOL (SAJOUS). 


formed by Simmonds in Hamburg, 
alcoholism could be excluded in 14; in 
60 it was evident, and in 26 there was 
no reliable information as to alcohol; 
therefore, it must be concluded that, 
while only a very small proportion of 
drunkards suffer from cirrhosis (about 
4 per cent), there are not a few cases 
of advanced cirrhosis which are not 
due to alcoholism, although alcohol is 
responsible for far more than a major¬ 
ity of all cases of cirrhosis. On the 
other hand, in nearly every case of 
habitual drunkenness the liver shows 
fatty changes, usually severe, but not 
ordinarily associated with connective- 
tissue increase, and this is by far the 
most frequent change in alcoholism. 
Editorial (Jour. Amer. Med. Assoc., 
Nov. 27, 1909). 

The writer from his immense ex¬ 
perience with wine drinkers in Italy 
is able to detect much exaggeration 
in many articles published. The 
actual amount taken daily and the 
proof of the wine are of great prac¬ 
tical significance. There is a utiliz- 
able limit. The use of small amounts 
with meals only is regarded as in¬ 
nocuous. A ‘‘small bottle” of wine 
which contains from 20 to 30 grams 
of alcohol answers this requirement. 
Anywhere from 40 to 70 grams alco¬ 
hol daily is regarded as the limit of 
safety beyond which a definite action 
on the nervous system may be per¬ 
ceptible. A daily consumption of 
from 300 to 600 grams of wine means 
the same thing. The writer con¬ 
cludes that a minimal use of wine is 
not only innocuous, but perhaps salu¬ 
tary. Bianchi (Riforma Medica, Oct. 
23, 1916). 

(2) Nervous System .—In many 
cases alcohol acts most prominently as 
a motor paralyzer, the control over the 
muscles being greatly impaired. The 
hands are unsteady in their movements, 
and protrusion of the tongue is im¬ 
perfect. Ultimately paralysis is a pos¬ 
sibility. 

In other cases cerebral symptoms are 
especially marked, the prolonged action 


% 

of the narcotic having caused a gradual 
loss of mental power. Normal cerebral 
activities are replaced now by exhilara¬ 
tion, again by depression. The subject 
becomes sluggish mentally, weak mor¬ 
ally, and loses in memory and will 
power. He may also show great irrita¬ 
bility, or be in a continuous state of ex¬ 
citement. His ideals are changed, and 
egotistic tendencies appear. Later, evi¬ 
dences of abnormal cerebration may oc¬ 
cur in the form of varying delusions and 
delirium. Permanent dementia is the 
terminal stage in this morbid chain of 
events, the patient becoming in his de¬ 
lusions timorous, suspicious, and some¬ 
times grandiose. The symptoms of 
simple or multiple neuritis are also 
very frequently seen in cases of alco¬ 
holism, occasionally to the extent of 
permanent local paralysis (see Alco¬ 
holic Neuritis under Neuritis). 

Alcoholic insanity presents special 
characteristic features which it is not 
difficult, in the majority of cases, to 
distinguish from other analogous con¬ 
ditions. Acute cerebral alcoholism pre¬ 
sents 3 states: delirious, confusional, 
and stuporous. The intensity of these 
states varies according to whether we 
deal with a subacute form or with 
delirium tremens. 

The chronic form leads inevitably to 
dementia. In the course of develop¬ 
ment of the latter, delusions with 
hallucinations and illusions may and 
may not manifest themselves. 

In the latter symptoms it may some¬ 
times present a picture of any other 
psychosis; this resemblance is only ap¬ 
parent, as in the majority of cases close 
observation will enable us to find the 
proper interpretations. 

If the symptoms characteristic of 
cerebral alcoholism sometimes de¬ 
velop in individuals affected with 
other psychoses who happen to com¬ 
mit excesses, or do so because of the 
perverted mode of thinking or feeling 
caused by the psychoses, it does not 
follow that alcohol is capable of 


ALCOHOL (SAJOUS). 


523 


producing these psychoses. The con¬ 
ception of alcoholic melancholia, 
mania, paranoia, or paresis is un¬ 
scientific. Alfred Gordon (Jour, of 
Inebriety, Winter, 1908-9). 

(3) Circulatory System. — Alcohol 
causes irritation of the intima of the 
vessels and gradual degeneration of the 
vascular walls. The symptoms pro¬ 
duced are those usual in widespread 
arteriosclerosis: vertigo, hemorrhage 
or thrombosis of the cerebral vessels, 
etc. The heart and kidneys are very 
likely to be involved as a result of the 
same changes and undergo correspond¬ 
ing alterations in function. 

In some instances the heart seems 
seriously affected. The patient com¬ 
plains of distress and pain over the 
precordial region, with alternate feel¬ 
ings of exhaustion and exhilaration. 
The pulse is frequent, and surface con¬ 
gestion is very intense. The heart may 
become dilated. 

Blood-pressure estimates were made 
in a series of 150 soldiers, all aged 
42 to 43 years. Among the 16 sober 
subjects, only 6.25 per cent, showed 
high blood-pressure; of 53 moderate 
drinkers, 7.54 per cent, showed high 
pressure; of 57 heavy drinkers, 17.54 
per cent., and of 24 very heavy drink¬ 
ers, 25 per cent. The conclusion is 
reached, therefore, that alcoholism is 
an important factor in the etiology 
of arterial hypertension. C. Lian 
(Bull, de I’Acad. de Med., Nov. 9, 
1915). 

(4) Kidneys .—Chronic parenchyma¬ 
tous nephritis is not uncommonly 
caused by prolonged alcoholic excesses. 
Its manifestations include disorders of 
digestion, increased vascular tension, 
anemia with characteristic translucent 
pallor, tendency to swollen face and 
extremities, together with more or less 
distinctive changes in the urine. The 
latter consist of abnormalities in quan¬ 
tity (at first diminished, later in¬ 


creased), lower specific gravity, albu¬ 
minuria ; granular casts, sometimes 
fatty; epithelial and waxy casts, and 
decreased proportion of urea. The late 
symptoms include marked weakness, 
general anasarca, dyspnea on exertion, 
and uremia. 

Report of observations made on a 
German guide in Berlin some years 
The man regularly drank over 
20 liters (quarts) of beer a day. He 
started with a couple before break¬ 
fast, 4 between breakfast and lunch, 
a couple of liters at lunch, 3 more 
before dinner, and the remainder be¬ 
tween dinner and bedtime. Most of 
it was the strong Munich beer, with 
6 to 8 per cent, of alcohol. The man 
thus consumed over 37 ounces of ab¬ 
solute alcohol a day. Yet he did not 
exhibit the least sign of inebriety. 
The case proved to the writer’s satis¬ 
faction that where alcohol is diluted 
20 or 30 times with water, it is al¬ 
most non-intoxicating. 

In view of the enormous quantities 
of beer consumed in Berlin, he sought 
in the hospitals evidences of cirrhosis 
or other signs of alcoholic poisoning. 
He found no more than would be 
shown by any other city of its size. 

In Munich, he was told, there are 
some evidences of cardiac hyper¬ 
trophy, due to the strain of pumping 
so many gallons of fluid through the 
kidneys. Walter (Brit. Med. Jour., 
Nov. 6, 1920). 

DIAGNOSIS.—This is facilitated 
if a history of excessive use of alcohol 
—at times in the form of proprietary 
remedies—be obtainable. If not, alco¬ 
holism is suggested by the presence of 
symptoms such as those given- in the 
beginning of the section on symptoms, 
these representing mainly functional 
■derangements and toxic effects, but 
few of them being the results of organic 
alterations. Active treatment is then 
begun. Under rest, restricted diet, and 
hydrotherapeutic measures many of 


524 


ALCOHOL (SAJOUS). 


these symptoms disappear, leaving only 
those expressive of permanent lesions. 

A careful re-examination at the end 
of two or more weeks will now indicate 
how many of the symptoms were func¬ 
tional, and which of them seemingly 
were organic departures from health. 
The special effects of the alcohol on 
particular organs or systems of the 
body are ascertained by noting the 
presence of symptoms referable to 
them, such as have already been men¬ 
tioned under that heading. It must be 
admitted, however, that in many cases 
the symptoms will appear very com¬ 
plex and refer to no particular seat of 
organic disease. 

At this second examination the diag¬ 
nosis of the patient’s psychic state can 
also be made with some accuracy. This 
should comprise a study of the pa¬ 
tient’s powers of reasoning, of his 
ideals, of his ethical conceptions of 
life, of the end and object in living, of 
his purposes and ambitions, of the ef¬ 
fects of losses and mental strains on 
his character, of the dominance of cer¬ 
tain passions and unrestrained emo¬ 
tional activities, and of the presence of 
morbid impulses and egotism. The 
inquiry should extend to the every¬ 
day habits of the patient. Not infre¬ 
quently periods of unexplained absence 
from home and business, and of unex¬ 
pected and obscure conduct, will be 
revealed. Such occurrences justify the 
inference of the paroxysmal use of al¬ 
cohol. Often the pronounced convic¬ 
tions of the patient as to the cause of 
his condition are significant of the use 
of spirits, which he denies. The diag¬ 
nosis can then be made with great 
clearness not from what he says, but 
from the facts he conceals or appears 
to be trying to cover up. 

Material assistance will sometimes 


be derived from a study of the family 
history and past medical history. He¬ 
reditary tendencies, the diseases of 
childhood, profoundly exhausting fe¬ 
vers, and injuries to the body may all 
be of importance in reaching a decision. 

The heredity element in inebriety is 
considerable and is undoubtedly a 
powerful predisposing cause in in¬ 
ebriety. A history of decided intem¬ 
perance in the parents existed in over 
40 per cent, of the writer’s 700 cases, 
while 15 per cent, gave a history of 
defective ancestry; insanity, neurop¬ 
athy, drug addiction or tuberculosis 
being present on the maternal or pa¬ 
ternal side. Approximately 5 per 
cent, of the patients showed pre-ex¬ 
istent mental symptoms which could 
be differentiated. Some of these were 
distinct cases of psychasthenia, others 
were of the milder forms of manic- 
depressive insanity. Neff (Boston 
Med. and Surg. Jour., June 16, 1910). 

The influences and conditions sur¬ 
rounding the subject at the period of 
puberty, the effects on him of losses 
and failures early in life should likewise 
be ascertained, since they may have a 
marked bearing on the establishment 
of vicious habits. If alcohol has been 
taken, no matter how moderately at 
first or at what long intervals, its in¬ 
fluence upon subsequent morbid devel¬ 
opments should be given due consider¬ 
ation. 

Where the symptoms are complex 
and the diagnosis obscure, it is usually 
safe to give prominence to alcohol as 
a causative factor. In many such cases 
alcohol is used to conceal the taking of 
other drugs. The diagnosis can then 
only be a tentative one, the strong 
probability of an alcoholic neurosis be¬ 
ing, however, kept in mind. It may 
have to be altered at any time upon the 
discovery of new facts in the patient’s 
history or in his present condition. 


ALCOHOL (SAJOUS). 


525 


PATHOLOGY.— In this are in¬ 
cluded changes in a large number of 
organs and tissues. It has been 
shown, indeed, that alcohol has de¬ 
structive effects on protoplasm in 
general. Hence, cellular elements 
of all kinds are open to its action, 
though it has been recognized that 
it is the most highly differentiated 
cells, such as those of the nervous sys¬ 
tem, which are the most easily affected. 
Its influence on the cells is exerted by 
reduced oxidation and altered metabo¬ 
lism. Destroyed cells, in virtue of a 
low-grade inflammatory process it 
produces, are replaced by connective 
tissue. The effect of alcohol in dimin¬ 
ishing oxidation is most prominently 
expressed in the failure to oxidize fats 
normally, with consequent accumula¬ 
tion, as in the liver and subcutaneous 
tissues. 

PROGNOSIS. —This is generally 
very favorable. Statistical studies in 
well-conducted institutions show that 
at least one-third of all the cases 
are permanently restored. The state¬ 
ments that 90 per cent, are cured have 
reference to present conditions, and 
are probably true for a limited time. 
On the turn of the drink cycle relapse 
occurs, and ^ter recovery. 

The largest insurance companies in 
America and in England show statis¬ 
tically that the average mortality rate 
among total abstainers from alcohol 
is 68.4 per cent, of the expected rate, 
whereas that of the non-abstainer is 
91.5 per cent., a difference of 23.1 per 
cent. This means a reduction of two 
and a third years in the average life 
of a non-abstainer. W. E. Porter 
(Med. Rec., Oct. 20, 1915). 

Statistics of cure are unreliable. In 
the treatment by gold chloride 95 per 
cent, were claimed to be cured. At the 
end of one year after treatment 55 per 


cent, had relapsed. At the end of the 
second year another 20 per cent, began 
to drink again. In the third only 10 
per cent, continued temperate and free 
from spirits. On the other hand, at 
Binghamton, N. Y., where the first 
exhaustive study was made of the sub¬ 
sequent history of 1100 patients, ten 
years after they had been treated, the 
results showed 61 per cent, still temper¬ 
ate and well. These and other statis¬ 
tics, while open to error, clearly suggest 
that at least 33% per cent, may be rea¬ 
sonably considered permanently re¬ 
stored. 

The future of the inebriate depends 
largely on the removal of the exciting 
causes, whatever they may be, and their 
avoidance in the future. In a certain 
number of cases there is a complete 
cessation and physiological change in 
the organism in which the impulse to 
use spirits passes away forever. This 
is now well known. It cannot be pre¬ 
dicted, but it occurs so often that we 
cannot but credit the results to greater 
knowledge, and to the use of more ex¬ 
act means in the treatment. 

It may be stated that the prognosis 
is always good, even in cases that have 
apparently reached the terminal stage. 
This prediction refers specifically to the 
craze for alcohol. This dies out, is 
overcome by drugs and rational treat¬ 
ment, while other conditions of degen¬ 
eration may remain. 

The alcoholic or inebriate is a com¬ 
pound of a great variety of causes, the 
removal of which brings about cure. 
Sometimes those causes are very insig¬ 
nificant, sufficiently so, in fact, to be 
readily overlooked. 

The use of tobacco changes the 
prognosis greatly, according to the 
writer, who has arrived at these con¬ 
clusions against his previous preju¬ 
dices. Among those alcoholics who 


526 


ALCOHOL (SAJOUS). 


have otherwise a good prognosis, the 
chances are even that he will return 
to alcoholism if he is a cigarette 
smoker. If he smokes a pipe or cigar 
the chances are about 3 to 2 that he 
will not return.. If he does not 
smoke at all the chances are about 8 
to 2 that he will not return. Lambert 
(Boston Med. and Surg. Jour., Apr. 
25, 1912). 

TREATMENT.—This resembles 
the prognosis in uncertainty and wide 
variations, indicating beyond ques¬ 
tion that the subject has been scarcely 
touched. Both hospital and home 
treatment, and even moral measures, 
show examples of permanent restora¬ 
tion. The field is very wide and 
largely unknown. 

Soon after prohibition was en¬ 
forced, the deaths in Petrograd dur¬ 
ing the first 4 months decreased by 
50 per cent, and for some months 
even more so. During the 3 months 
preceding the writer’s paper, how¬ 
ever, it had risen again to the for¬ 
mer standard, or even higher, owing 
to the drinking of denatured alcohol, 
furniture polish and other substitutes 
for vodka. Therefore the effects of 
prohibition are not decisive. Novo- 
selsky (Roussky Vratch, No. 15, 1915). 

Home Treatment.—First, there is 
the home treatment, i.e., care given to 
the patient in his own home by the 
family physician. It is evidently pos¬ 
sible to restore many persons, partic¬ 
ularly if they give their full assent and 
co-operation and carry out the meas¬ 
ures laid down for them. 

Home treatment requires implicit 
confidence in the medical adviser, and 
should consist ‘of the absolute with¬ 
drawal of spirits and the use of 
means and measures to restore and 
relieve the conditions of starvation 
and poisoning present. 

While the causes differ in each case, 

their removal and the after-treatment 


are substantially the same. Thus, one 
whose living, both in regard to nutri¬ 
tion and rest, is bad requires a change. 
Nerve rest and regular* diet must be a 
part of the treatment. 

In one who has become poisoned 
by spirits and highly stimulating 
foods, the withdrawal of these agents 
and rest are essential. Probably hy¬ 
dropathic measures to insure elimina¬ 
tion by means of the skin represent 
the most effective method of treatment. 

Many of these patients are suffering 
from delusional egotism and inability 
to recognize their condition (con¬ 
stantly overrating their strength), 
and are unwilling to use the means 
so evidentj tb others. The family 
physician should be dogmatic and ex¬ 
act the use of means and measures 
that will break up the impulse to 
use spirits. He should treat the pa¬ 
tient mentally as well as physically, 
and the danger of the situation should 
never be minimized; he should not 
permit the patient to think that he 
can depend on his own will to over¬ 
come his diseased impulses. In many 
instances the patient is impressed with 
the gravity of his disorder. He must 
be urged to make radical changes in 
his living and conduct. If his work 
is indoors, a change to^ out-of-door 
life is requisite. If he has neglected 
proper exercise, this should be ar¬ 
ranged for* in some satisfactory way. 

The writer has employed hypnotic 
suggestion in 1284 cases of alcohol¬ 
ism, principally chronic. Favorable 
results were obtained in 80 per cent. 
In view of the ease of application and 
freedom from any bad effects, the 
author urges the general employment 
of this method. Zausailoff (Roussky 
Vratch, Aug. 4, 1912). 

Everything that will change the pres¬ 
ent current of thought with mental and 
physical activity belongs to rational 


ALCOHOL (SAJOUS). 


527 


treatment. Of course, with this, ap¬ 
propriate remedies and measures to 
neutralize and diminish exciting causes 
will suggest themselves to the physi¬ 
cian. He should recognize that these 
are often border-line cases in which 
both reason and will are clouded and 
the patients are irresponsible. They 
need suggestion, forcible and em¬ 
phatic; physical treatment, and per¬ 
sistent use of all therapeutic means. 
The family physician can do a great 
deal in this field if he will prepare 
himself for it and study the peculiar¬ 
ities of the patient. 

Office Treatment.—This is equally 
promising in results where the patient 
is recognized by the physician and 
his condition understood. Drug 
treatment forms a very important 
part of the means to bring relief. 
Probably the most practical drugs 
are combinations of strychnine and 
atropine, given at short intervals for 
a few weeks, then replaced by some 
other agent. 

Favorable report of treatment, es¬ 
sentially that first proposed by Mc¬ 
Bride, which consists in the hypo¬ 
dermic injection of atropine and 
strychnine twice or thrice daily for a 
month or six weeks, with attention 
to general hygienic condition, and 
tonics by mouth. Patients were told 
that success depended on regular at¬ 
tendance. The writer reports 7 cases, 
all presenting marked degrees of al¬ 
coholism. In 5, treatment was com¬ 
menced in September, 1905; July, 
1907; March, 1908 (2 cases), and 
July, 1909, respectively. These cases 
had remained cured up to date. W. 
Asten (Lancet, Nov. 6, 1909). 

Reference made to Ferran’s anti- 
alcoholic serum, obtained by adminis¬ 
tering wine to horses. The serum is 
collected when the animal presents 
reactions on the part of the system 
corresponding to those of acute al¬ 
coholism. The serum was tried clin¬ 


ically in chronic alcoholics. Subcu¬ 
taneous injection of the serum seemed 
to afford to the system improved 
powers of resistance against intoxi¬ 
cation. The patients experienced a 
marked sense of euphoria after the 
injection, and were enabled to react 
against the exhaustion or “suppres¬ 
sion neurasthenia” arising from com¬ 
plete cessation of alcoholic imbibi¬ 
tion. Berillon (Prasse med., Dec. 6, 
1919). 

The impulse to drink may be effect¬ 
ually controlled by small doses of 
apomorphine given hypodermically or 
by the mouth. Concentrated aqueous 
infusion of quassia given every hour 
very quickly breaks up the drink im¬ 
pulse, and frequently destroys the 
taste for tobacco, which is often a 
very important factor in the use of 
spirits. 

In the office tretitment care should 
be exercised not to substitute for 
spirits narcotic drugs that are likely 
to produce poisonous effects if taken 
without caution. Chloral hydrate is 
one of these drugs, commonly admin¬ 
istered, but it is unsafe and danger¬ 
ous ; also many forms of opium and 
its derivatives. 

Humulus is a narcotic of great 
power at times, and is often an excel¬ 
lent substitute for spirits. It is not 
wise to give tinctures to patients who 
come to the office for treatment. Give 
infusions always. Salines are very 
practical measures and can be given 
freely without risk. 

Office patients of this class want 
remedies that will impress them at 
once; hence, the physician must study 
the drugs whose effects are more or 
less certain. Sodium bromide is a 
favorite drug, and can be used with 
safety; only, the physician must 
realize that it is cumulative in its ac¬ 
tion, and that baths, cathartics, and 


528 


ALCOHOL (SAJOUS). 


diuretics are to be associated with its 
use constantly. 

Office patients should be urged to 
take daily baths and exercise in the 
open air, but should be impressed 
psychically with the need of avoiding 
causes which lead or predispose to 
exhaustion. It is impossible to spec¬ 
ify particular drugs and a plan of 
treatment applicable to every case. 

The conditions vary so widely and 
the active and exciting causes de¬ 
pend on SO many circumstances—sur¬ 
roundings, occupation, success or 
failure in life, diet and social influ¬ 
ences, rest, etc.—that each case be¬ 
comes a law unto itself, and requires 
a very close study of the conditions 
present. 

Hospital Treatment.—This is far 
more successful, particularly in per¬ 
sons who have reached the later stages 
of degeneration. It is a common ex¬ 
perience to have persons go to a hos¬ 
pital or sanatorium and recover from 
the immediate eilects of spirits, and 
have a period of rest, change, and thor¬ 
ough elimination of the active exciting 
causes. They can then return to the 
family physician and remain under his 
care for an indefinite period. It often 
happens that hospital treatment and re¬ 
straint is the only measure that has 
any promise of permanency. Such 
hospital treatment is efifectual by 
combining hydrotherapeutics and 
sanitary appliances with hygienic 
measures specifically adapted to meet 
the wants of every person. 

Drugs are very essential adjuncts 
and aid materially in restoring the 
vigor and metabolism of the body. 
Diet and exercise are also very im¬ 
portant remedies. These, with nerve 
rest, change of thought and surround- 
ings, are followed by restoration, 


and where these measures are con¬ 
tinued over a certain length of time 
the cure is permanent. 

The actively working inebriates 
and alcoholics who are carrying loads 
of responsibility need hospital-homes 
in the country or by the seashore 
where absolute rest and quietness can 
displace their usual unhygienic ac¬ 
tivities. The diet, exercise, baths, 
electricity, tonic drugs, new duties, 
and new conceptions of their actual 
conditions must be forced upon them 
and become a part of their everyday 
life. 

Here psychic therapeutics comes 
in as a very important means of treat¬ 
ment, and as a supplement to other 
and physical remedies. A sanatorium 
hospital will supply these needs, af¬ 
ford a clear knowledge of the pa¬ 
tient’s condition, and train him in the 
conduct he should observe in the 
future. 

Stress laid on distinction between 
the willful and the will-less drinker. 
The former are men of great energy, 
who firmly believe they can protect 
themselves from all abuse of drink. 
The habit is thus readily acquired 
and is associated with an imperious 
daily craving. When they seek to 
resist it they only defer it by some 
hours. They then deliberately weigh 
the apparent gains with the sacrifices 
and make a choice. The problem is 
a very old one, and the wise man has 
often played a trick on his subcon¬ 
scious self and its burning desire 
rather than test his will too openly. 
Thus Cesar Borgia, after having be¬ 
come a heavy addict to wine, reduced 
the capacity of his glass by the cumu¬ 
lative addition of drops of melted wax 
until he had weaned himself from the 
desire. A more rapid process con¬ 
sists in rendering the drink nauseat¬ 
ing by the addition of ipecac. The 
psychology of the willful drinker is 
best explained by the creation of a 


ALCOHOL (SAJOUS). 


529 


second personality through the ad¬ 
diction, which is subject to its own 
laws. While the strong subject may 
become an aboulic as a result of pro¬ 
longed addiction, there are others 
who are aboulic by nature, and who 
put up no struggle at all. These 
subjects are best adapted to psycho¬ 
therapeutic management Jaguaribe 
(Bull, med.. Mar. 17, 1920). 

There are many hospitals and sana¬ 
toria with varied measures of treat¬ 
ment, but in none of those worthy of 
confidence are there any specifics en¬ 
veloped with mystery. The treatment 
has passed beyond the empiric stage, 
and is now as thoroughly fixed with its 
positive results as that of any other 
disease, and, there are no specifics 
or combinations of drugs that can 
effectually check the drink impulse 
unless at the peril of its breaking out 
again with greater force. 

GENERAL TREATMENT.— Ev¬ 
ery inebriate is toxemic, and every 
attack of drunkenness is a period of 
exacerbation of this toxemia. The 
first measure is to withdraw the spir¬ 
its and remove the poison by stim¬ 
ulating the bowels and the skin to 
insure its elimination. Calomel, either 
in a large dose of 10 grains or a small 
dose of 1 grain every two hours, until 
6 or 8 grains are taken, together 
with salines, are the most effective 
cathartics, and should always be used 
at the beginning. 

If the patient objects to the sudden 
removal of alcohol, and his condition 
borders on delirium, %o of a grain of 
apomorphine hypodermically should 
be given as a relaxant. This will be 
followed by vomiting, free perspira¬ 
tion, and sleep. On awakening a hot 
bath of the temperature of 105° or 
110° should be given. If the patient will 

consent to lie in the bathtub for an 

1-34 


hour or two at a time, then be rubbed 
down and recline in a cool room, ex¬ 
cellent effects will be obtained. If 
he will not, an oixiinary hot bath 
should be followed by a vigorous 
hand rubbing and reclining in bed. If 
the desire for spirits continues and 
the depression is not marked, 
grain of strychnine with y 2 oo of atro¬ 
pine should be given every two hours. 

To get a man on his feet with a clear 
brain, and with the craving for nar¬ 
cotics removed, a mixture of drugs 
given to the writer by Mr. Charles B. 
Towns has proven of value. It con¬ 
sists of a mixture of 15 per cent, tinc¬ 
ture of belladonna, 2 parts, and 1 part 
each of fluidextract of xanthoxylum 
and fluidextract of hyoscyamus. 

From 6 to 8 drops of this are given 
every hour, day and night, until either 
the patient shows symptoms of bella¬ 
donna excess or, with the cathartics 
about to be described, the patient has a 
certain characteristic stool. This dose 
of the mixture is increased by 2 drops 
every six hours, until 14 to 16 drops 
are being taken; it is not increased 
above 16 drops. Usually an alcoholic 
can be given 4 compound cathartic 
pills (U. S. P.) at the same time 
that the specific is begun. After the 
mixture has been given for fourteen 
hours, a further dose of C. C. pills is 
given, either 2 or 4, depending upon the 
amount of action obtained through the 
use of the previous dose. If these have 
acted very abundantly, only 2 are now 
necessary. At the twentieth hour of 
the mixture 2 to 4 more C. C. pills are 
given, and after these have acted, 
should the patient begin to show abun¬ 
dant green movements, an ounce of 
castor oil should be given, and a few 
hours later the characteristic thick, 
green, mucous, putty-like stool will 
appear. Usually the mixture has to 
be continued, and at the thirty-sec¬ 
ond hour 2 to 4 C. C. pills are again 
given, and a few hours later the cas¬ 
tor oil. The mixture can then be 
discontinued. 

Of course, in treating alcoholics 


530 


ALCOHOL (SAJOUS). 


one finds in the majority of cases the 
necessity to stimulate them and to 
give them some hypnotic, but this 
can be done without Interfering with 
the hourly administration of the 
above. Alexander Lambert (N. Y. 
State Jour, of Med., Jan., 1910). 

The belladonna treatment properly 
given will totally eradicate the phys¬ 
iological craving for narcotic drugs, 
including alcohol. To secure perma¬ 
nent results it is necessary to pay as 
much attention to the after-care in 
both alcoholic and drug cases as is 
given to the derivative treatment. 
This after-care consists in regular 
supervision over several months and 
a thorough understanding of the 
needs of the patient by both himself 
and his friends. The treatment con¬ 
sists in the hourly administration of 
a mixture of belladonna, hyoscyamus, 
and xanthoxylum, in connection with 
increasing vigorous catharsis at 
stated intervals. At the end of this 
course a so-called “typical stool” is 
obtained, and the patient emerges 
into a very unusually comfortable 
condition with little or no craving re¬ 
maining. There are several points to 
be noted about this vigorous deriva¬ 
tive treatment. The belladonna mix¬ 
ture must be pushed to the physio¬ 
logical limit and not beyond. Atro¬ 
pine poisoning must be sighted, but 
not reached. To fall short of this 
point spells failure to actually ob¬ 
literate the craving; to overstep it 
intimidates the patient. Ross Moore 
(So. Calif. Pract., July, 1911). 

If the restlessness and excitement 
continue, repeat the apomorphine 
in % 0 -gTain doses every two hours. 
Should the stomach be irritable, use 
hot and cold fomentations over it, 
and give carbonated waters, usually 
Vichy. The patient should not take 
any food, for, as a rule, digestion is 
impaired to the extent that food can¬ 
not be assimilated. 

If the patient is restless and insists 
on moving about, have an attendant 


go with him and walk him until he 
shows fatigue, then bring him back 
and give a hot tub bath or shower 
with apomorphine and strychnine. 

Never give chloral or morphine. 
The latter may be used under special 
circumstances, but the former is con¬ 
traindicated. For the insomnia lupu- 
lin, valerian, cannabis indica, and 
other vegetable narcotics may be 
given, but never in the form of tinc¬ 
tures. 

Often some of these drugs produce 
sleep at once. Others have little or 
no effect and should not be given. 
The size of the dose will depend upon 
the apparent sensitiveness of the pa¬ 
tient to the effects. 

Occasionally, where there is a tend¬ 
ency to delirium, bromide of sodium 
in from 50- to 100- grain doses may 
be used. Not more than 3 or 4 doses 
at intervals of three hours should be 
given. After giving this drug the 
patient should take a hot bath, which, 
has the effect of producing more 
rapid absorption of the salt. Some¬ 
times a salt bath is preferable to 
plain water, if there is much de¬ 
pression. 

In the severe types of acute alco¬ 
holic delirium that have come under 
observation, 64 cases have all given 
evidence of a severe acid intoxica¬ 
tion. The symptoms represent the 
effects of the alcohol on the nervous 
system and liver, and the pathologic 
changes may range from simple 
edema to severe degenerative changes 
of the fatty type. Any treatment, to 
be of service, therefore is indicated 
in the stage of edema. After experi¬ 
mental work with various salts that 
have the power of dehydrating 
edematous tissues, he devised a mix¬ 
ture of sodium bromide, sodium 
chloride and sodium bicarbonate that 
could be used in large quantities in¬ 
travenously without producing the 


ALCOHOL (SAJOUS). 


531 


toxic effect of bromide as ordinarily 
given in large doses. As the severe 
types also suffered from starvation 
acidosis, glucose in high concentra¬ 
tion was also used intravenously; 
this not only furnished an available 
carbohydrate that was readily utilized 
by the body, but in 30 per cent, con¬ 
centration produced marked dehy¬ 
drating effects on the central nervous 
system. 

In the preparation of the solutions 
5.8 Gm. (I'lio drams) of chemically 
pure sodium chloride and 8.4 Gm. 
(2Vio drams) of chemically pure 
sodium bicarbonate were boiled in 
120 c.c. (4 ounces) of distilled water 
and filtered through paper, then 
placed in a flask and reboiled. In 
addition 10.2 Gm. (2l4 drams) of 
chemically pure sodium bromide 
were boiled in 30 c.c. (1. ounce) dis¬ 
tilled water, filtered and reboiled. 
These may be kept ready for use, 
and when needed are added to 850 
c.c. (2814 ounces) of either freshly 
distilled water or tap water that has 
been filtered and boiled. Under no 
circumstances should old distilled 
water be used, as it has been found 
that it produced severe chills. This 
mixture is heated to about 110® F. 
(43.3° C.) and is ready for use. Both 
of these solutions must be given 
very slowly, from 20 to 30 minutes 
being taken for the 1250 c.c. (214 
pints) or 1000 c.c. (2 pints) employed. 
A small percolator, such as is used in 
giving salvarsan, with rubber tubing 
and needle attached, is all the ap¬ 
paratus that is needed. 

The mortality was lower, 9.3 per 
cent.; the time of detention less, an 
average of 2.63 days, and the period 
of delirium much shortened. The 
patients ate better. The desire for 
alcohol was abolished, at least for 
the time being. J. J. Hogan (Jour. 
Amer. Med. Assoc., Dec. 16, 1916). 

Cinchona bark in infusion has a 
very good effect, and infusion of 
quassia chips is another remedy of 
great value, but for the acute stages 
hot water, hot baths are most prac¬ 


tical. In the course of a day or so a 
disgust for spirits begins. In the 
mean time salines should be given 
and the bowels kept loose. 

The strychnine combination should 
be kept up, and should the atropine 
symptoms appear the size of the dose 
diminished. Food should be taken 
very sparingly for the first two days. 
After that a diet rich in cereals and 
malted milk may be given. 

As a rule, milk is not a good diet 
for these cases. Coffee and tea may 
be used according to the taste of the 
patient. Exercise in the open air and 
reclining in a cool room, with nerve 
rest, are very essential. 

The disposition of the patient to 
eat inordinately should be suppressed. 
If there is a tendency to constipation, 
mineral waters that are laxative on 
an empty stomach should be given. 

According to Hall caffeine is al¬ 
most a specific in alcoholic toxemia. 
This drug in doses of 1 to 2 grains 
every one, two, or three hours will usu¬ 
ally, in from twenty-four to forty-eight 
hours, quench the thirst or craving for 
alcohol to such an extent that the most 
confirmed habitues will voluntarily 
abandon its use. 

Elimination through the skin, bow¬ 
els, and kidneys should be the main 
purpose of the treatment, all with 
proper nutrition and rest. Where 
there is a history of specific disease, 
mercury or arsenic in small doses is 
required. When the paroxysm sub¬ 
sides and the patient is restored, the 
great question becomes to determine 
the exciting causes which produce 
the return of the drink craze, and as¬ 
certain their periodicity. 

In most cases it is wise to discon¬ 
tinue the strychnine compound and 
continue the free use of baths, care- 


532 


ALCOHOL (SAJOUS). 


fully regulated diet, with salines, for 
some time, until evidence of the re¬ 
turn of the drink craze appears. 

If the patient keeps in close touch 
with the family physician his diges¬ 
tion, nervous symptoms, and habits 
of living can be studied and properly 
treated. Where possible, Turkish 
baths, with prolonged rest afterward, 
should be given at least once or twice 
a week. 

If the physician can secure the full 
confidence of the friends as well as 
the patient, and impress upon him 
the necessity of extraordinary care 
and the methodical use of hydro¬ 
pathic measures, a great deal can be 
accomplished. 

In the country, baths may be im¬ 
provised in a tub, and water falling 
on the patient in a narrow stream 
has an excellent sedative efifect. Hot 
packs or sheets wrung out in hot or 
cold water covering the body, over 
which are spread dry blankets, pro¬ 
ducing intense or rapid perspiration, 
are often most valuable. 

The physician should always study 
the digestion of the patient and de¬ 
termine the states of acidity or alka¬ 
linity of the stomach and correct 
them as required. 

Exhaustion and depression fre¬ 
quently precede a drink impulse. 
Small doses of ipecac, ^ of a grain 
given at intervals of two hours, pro¬ 
duce a pronounced relaxing effect, 
and where the patient has high-ten¬ 
sioned arteries and excitable pulse 
this is an excellent remedy. 

Quassia chips in a concentrated so¬ 
lution are almost a specific for the 
drink craze, but they must be given in 
large doses at intervals of an hour or 
so, and followed by free use of ca¬ 
thartics and baths. Quinine has some 


value, particularly where there is 
a history of malaria, but it should not 
be used more than about two weeks. 

All such cases are self-limited and 
will recover with the use of hygienic 
measures. The great value of the 
physician is to determine and remove 
the causes and, where there is a peri¬ 
odicity in the return of the paroxysm, 
to have the patient under treatment 
and anticipate this condition. 

The treatment of drug and alcohol 
habitues with hyoscine will remove 
the desire for these drugs, thus elim¬ 
inating the element which prevents 
the patients from abstaining by force 
of will power. Having lost the de¬ 
sire, they do very well without in¬ 
toxicants or the drugs, as shown by 
the increase in appetite, gain in flesh, 
and their general improvement. The 
question of relapse lies entirely in the 
sincerity and environment of the 
patient. The favorable alcoholic ad¬ 
dicts are those who earnestly desire 
to discontinue the use of intoxicants 
and are willing to change their mode 
of living and environment, but who 
cannot until relieved of the craving 
for liquor. Relapse in both drug and 
liquor cases is not due to a desire 
nor suffering after the treatment, but 
to their curiosity to test the necessity 
of total abstinence, or to the tempta¬ 
tions of social life. A single dose of 
the drug or drink of liquor, even af¬ 
ter 1 year of total abstinence, is very 
apt to start the craving, resulting in 
a condition which is no better than 
before treatment. This method may 
prove a valuable treatment in appar¬ 
ently hopeless cases of opium poison¬ 
ing. Interesting experiments along 
this line might be carried out. The 
one contraindication for this treat¬ 
ment is the presence of Bright’s dis¬ 
ease. No patient should be treated 
unless put to bed and watched by 
competent nurses day and night dur¬ 
ing the first week. Riewel (Monthly 
Cyclo. and Med. Bull., Oct., 1909). 

[The craving for stimulants is mainly 
due to the depression of the endocrins fol- 


ALCOHOL (SAJOUS). 


533 


lowing their abnormal excitation by alco¬ 
hol overdosage. The stage of excitement 
which typifies excessive metabolism and 
high vascular tension is replaced by vir¬ 
tual failure of the circulation of which the 
sympathetic (chromaffin) system, which 
includes the adrenals, sustains oxygena¬ 
tion, metabolism and also vascular tone 
particularly insofar as the arterioles are 
concerned. Hence the danger of too sud¬ 
denly withdrawing alcohol in such patients. 
Strychnine, i/4o grain (0.0016 Gm.), to 
stimulate the adrenals, posterior pituitary, 
Mo grain (0.0065 Gm.), to raise the vas¬ 
cular tension, and suprarenal gland 2 
grains (0.13 Gm.), in one capsule t. i. d., 
are efficient unless excitement prevail. In 
the latter case hydrobromide of hyoscine, 
Moo grain (0.0003 Gm.), hypodermically, 
which owing to its stimulating action on 
involuntary muscles tends to constrict the 
dilated arterioles, followed by potassium 
bromide 30 grains (2 Gm.), to inhibit the 
irritability of nerve centers, should first 
be administered. C. E. de M. S.] 

In delirium, opium and its deriva¬ 
tives and many of the other drug’s 
that are powerful narcotics should be 
avoided. All proprietary drugs are 
dangerous, and should be condemned 
no matter what the experience may 
be. Every physician is capable of do¬ 
ing far more for the relief of this con¬ 
dition by adapting the remedies to 
the particular case than by any widely 
exploited compound. 

A law, dealing with the repression 
of public drunkenness and the super¬ 
vision of saloons, has been promul¬ 
gated. It imposes on persons found 
in a manifest state of drunkenness on 
the streets a fine of from 1 to 5 
francs for the first offense. The 
second offense is punishable by from 
1 to 3 days’ imprisonment, and a 
third offense, when occurring within 
the first 12 months, is punishable by 
imprisonment for from 6 days to 1 
month or a fine of from 16 to 300 
francs. Any person who is convicted 
twice may be deprived of his elec¬ 
toral and civic rights for 2 years. 


The law fixes an analogous penalty 
for such dealers as shall serve liquors 
to minors (under 18), and dealers 
who are fined more than once will be 
liable to closure of their establish¬ 
ments for a year or more. The sale 
of alcoholic liquors on credit is in¬ 
terdicted. The law forbids the em¬ 
ployment of females under 18 years 
of age in retail liquor establishments, 
unless they are members of the pro¬ 
prietor’s family. Dealers who en¬ 
courage debauchery shall be impris¬ 
oned for from six days to six months, 
and shall forfeit their political rights 
for five years. Their establishments 
shall be closed permanently. Paris 
Letter (Jour. Amer. Med. Assoc., 
Nov. 17, 1917). 

ACUTE ALCOHOLIC DELIR¬ 
IUM, OR DELIRIUM TREMENS. 

—This is a condition of acute alcoholic 
poisoning, associated with exhaustion 
and cell starvation. It occurs chiefly 
in habitual drinkers, but it is also ob¬ 
served in ordinary temperate per¬ 
sons after a prolonged drinking spell. 
Though mostly met with in spirit 
drinkers, it is occasionally seen in 
beer, wine, and cider drinkers. 

SYMPTOMS. —Two forms are dis¬ 
tinguished : the traumatic and the idio¬ 
pathic. They differ little except in the 
prodromata. In the traumatic form, 
after an accident (sometimes only 
slight trauma) the characteristic tre¬ 
mors, etc., appear, frequently without 
warning. In the idiopathic form, the 
patient who is about to have an attack 
is restless, uneasy, irritable; he sleeps 
badly, if at all, suffers from (Jigestive 
troubles, and has little desire for food. 
Delirium then appears. The patient 
cannot rest, but must be in constant 
motion. He is shaking all over (“the 
shakes”), is consumed with terrors, 
continually in deadly fright of things 
which he mentalls sees, or of persons 
whom he thinks are after him for the 


534 


ALCOHOL (SAJOUS). 


commission of some crime. At other 
times his dread is of something ter¬ 
rible, though he cannot tell what it is. 
He is all the while trying to escape 
from these well-defined or undefined 
horrors, and, in the attempt to escape, 
fatalities sometimes occur. 

Hallucinations of various kinds, es¬ 
pecially of sight are most common: 
snakes, rats, mice, loathsome things, 
flames, and, in a case of the writer’s, 
roaring lions bounding down the chim¬ 
ney, below the chairs, and rushing in at 
the windows. According to Liepmann, 
visions of animals are present in 
40 per cent, of cases at most. The 
delirium is best described as one of 
busy wakefulness and suspicion. 
There is a third non-febrile, innocent 
form, in which the temperature does 
not rise above 100° F. 

Hallucinations of hearing are not 
so common, but exist in probably 10 
to 20 per cent, of cases. Delusions 
(false perceptions concerning self) 
are found in from 5 to 9 per cent.,— 
mostly delusions of persecution. 
Sometimes there is one hallucination, 
illusion, or delusion throughout; 
sometimes there is a succession. 

The tongue is white and furred. 
Tremor of this organ, and especially 
of other muscles, is a more or less 
marked and generally present symp¬ 
tom. 

The fever is not very high, being 
about 100° to 103° F. If higher, it is 
an unfavorable omen. The pulse is 
soft, rapid, and readily compressed. 
The skin is clammy. Insomnia is con¬ 
stantly present, but usually sleep and 
improvement occur on the third or 
fourth day. In unfavorable cases the 
patient grows gradually worse and 
finally dies of heart-failure (Norman 
Kerr). 


DIAGNOSIS. —Alcoholic delirium 
may be mistaken for the delirium of 
meningitis, of typhus and typhoid 
fevers, and of chronic alcoholism. 
The history and progress of the case 
determine the first two, and the ab¬ 
sence or significance of thirst, tongue 
trembling, and tremors the third. 

Report of tests on 8 patients show¬ 
ing that 325 Gm. of absolute alcohol 
must be ingested before any appears 
in the cerebrospinal fluid. 

It appears first in the urine, and 
disappears early here. 

In 5 other cases, alcohol found in 
the cerebrospinal fluid gave the clue 
to the diagnosis. In 3 it had been 
responsible for the fatal cerebral 
hemorrhage, at least 325 c.c. of alco¬ 
hol having been ingested. In a fourth 
it caused irregular epileptiform seiz¬ 
ures and impulsive violence which 
had been ascribed to the underlying 
epilepsy. In the fifth case, mental 
impairment and tendency to ataxia in 
the man of 54 were explained by the 
alcohol found in the lumbar puncture 
fluid during 18 days. When it finally 
disappeared from the fluid, all the 
symptoms subsided. 

The potassium bichromate and sul¬ 
phuric acid test of Grehant and 
Nicloux for alcohol was used. Le- 
noble and Daniel (Bull, de la Soc. 
Med. des Hop., Oct. 10, 1919). 

Pulmonary disorders; congestion, es¬ 
pecially when of traumatic origin, and 
pneumonia may also give rise to delir¬ 
ium simulating that of delirium tre¬ 
mens. Fractured ribs may thus become 
the primary, factor of violent accesses. 
The same may be said of erysipelas. 

PATHOLOGY. —Acute alcoholism 
is due to gradually produced changes 
in the nerve-tissues, and especially to 
retained products of metabolism. The 
cerebral lesions in alcoholic delirium 
are of two varieties. The first is 
observed in all alcoholics, and is due 
to the alcohol itself: atheromatous de- 


ALCOHOL (SAJOUS). 


535 


generation of the vessels, the degree of 
disorder increasing as the caliber of 
the vessel is reduced. The nerve-cells 
also show granular pigmentation and 
fatty degeneration. 

The second variety is derived spe¬ 
cially from the character of the delir¬ 
ium, and not from the alcohol itself. It 
consists in congestion, hematic pigmen¬ 
tation in the capillaries and nerve-ele¬ 
ments, and degeneration of the nerves 
and fibers of the cortex, the precursors 
of general paralysis (Norman Kerr). 

According to Jacobson, delirium 
tremens occurs when a brain, deterio¬ 
rated by chronic alcoholism, is influenced 
by a toxic agent, either due to the action 
of bacteria or to autointoxication from 
diseases of the digestive tract, the kid¬ 
neys, or the liver. 

The changes in the central nervous 
system and spinal ganglia are quite 
uniform; they consist essentially, first, 
in thickening of the walls of the 
arteries, proliferation of the connective 
tissue in the media, and dilatation and 
infiltration of the lymph-spaces. These 
changes are more pronounced in the 
cortex, and frequently lead to minute 
hemorrhages, as many as 200 of these 
having been counted in a square centi¬ 
meter of the cortex. The capillaries 
appeared to be proliferated, particu¬ 
larly in 1 case, but they and the veins 
showed no pronounced anatomical al¬ 
teration. The neuroglia fibers of the 
cortex showed, according to Weigert’s 
new method, considerable proliferation. 
The Weigert cells were more numerous 
than normal. The free nuclei, both the 
small and large varieties, were in¬ 
creased in number in the second and 
sixth layer of the cortex, and appeared 
to be accumulated around the degener¬ 
ating cells. The spinal cord was ap¬ 
parently normal (Tromner). 


Of 247 recovered personal cases of 
delirium tremens studied by Jacobson, 
202 were uncomplicated and 45 compli¬ 
cated by other diseases. Although the 
delirium tremens cannot be regarded as 
caused by the action of the pneumo¬ 
coccus, it resembles, in all its features, 
an infectious disease: it has a stage of 
incubation—a duration of about four 
days; it ends with a critical sleep; is 
accompanied by rise of temperature, 
and almost in all cases by albuminuria, 
and when autopsy is made the spleen 
is generally found to be the seat of 
parenchymatous degeneration, as well 
as the heart, the kidneys, and the liver. 

PROGNOSIS. —In private practice 
the prognosis is favorable in ordinary 
cases; in hospital practice it is much 
less so. Of 1241 cases admitted to the 
Philadelphia Hospital during a fixed 
period, 121 died. Recurrence occurs if 
drinking is continued. Norman Kerr 
noted recurrence from one to five times 
in 104 out of 442 cases treated in a spe¬ 
cial institution. 

TREATMENT.— The first indica¬ 
tion is to remove the causative tox¬ 
emia; this can be done by persistent 
and active hydropathic measures. 
Hypnotics are not always necessary, 
and may be dangerous. They should 
be avoided if possible. The best treat¬ 
ment is continuous baths, showers, sa¬ 
lines, restraint, exercise, massage, good 
air, and little or no food until the de¬ 
lirium subsides. The following repre¬ 
sents, however, the measures generally 
recommended in such cases:— 

The patient must be kept in bed 
and carefully watched. Strapping in 
bed should not be practised, as the 
restraint causes muscular movements 
and delirium. A sheet tied across the 
bed is preferable, as this allows more 
freedom of motion. Attendants or a 


536 


ALCOHOL (SAJOUS). 


padded room is best of all. No alco¬ 
hol should be given, the strength be¬ 
ing sustained by foods, milk, soups, 
etc. 

The immediate suppression of alco¬ 
hol in delirium tremens and the em¬ 
ployment of hydrotherapeutic meas¬ 
ures advised rather than of hypnotics; 
the former serve to increase and to 
maintain the activity of the heart, 
although one would expect an op¬ 
posite effect. In instances of cardiac 
weakness stimulants, strophanthus, 
digitalis, camphor, caffeine, are em¬ 
ployed, and in about three days, when 
the delirium begins to lessen, 30 to 
60 grains of chloralformamide are 
given; this quickly induces sleep. 
Thirst is controlled by bitter infu¬ 
sions. If pneumonia appears as a 
complication, digitalis and alcohol 
are administered. In these patients 
the prognosis is distinctly bad. Eich- 
elberg (Miinch. med. Woch., Bd. xx, 
S. 978, 1907). 

Potassium bromide, % <iram, with 
tincture of capsicum given every three 
hours, is recommended for mild cases 
by Osier. 

Sleep is, however, deemed neces¬ 
sary by some authorities. According 
to Lancereaux, for example, the real 
chance of recovery in alcoholic de¬ 
lirium lies in sleep. The patient is, 
therefore, isolated in a quiet, dark, and, 
if necessary, padded room, no physical 
restraint being employed. To procure 
sleep the patient is given 1 to 
drams of chloral hydrate, with % 
grain of hydrochlorate of morphine, 
in an infusion of limes. If sleep does 
not come on in about ten minutes, from 
% ^ grain of morphine is injected 

hypodermically. 

After the various alcoholic dis¬ 
turbances have subsided strychnine 
or nux vomica is given, followed by 
hydrotherapeutic measures. If there 
should be gastric complication, an 


antacid, such as sodium bicarbonate, 
is administered. 

The writer reports the result of 
five years’ use of veronal in delirium 
tremens. His method of administra¬ 
tion is as follows: An initial dose of 
1 Gm. is given in all incipient cases. 
If sleep does not follow within three 
hours, another gram is given. Sleep 
then follows and lasts six to eight 
hours, or even twelve. On waking 
the patient is clear, quiet, and feels 
well. If there is yet some tremor, 
0.5 Gm. of veronal is given, and by 
evening all tremor has, as a rule, dis¬ 
appeared. If the patient remains in 
the hospital some time longer for 
other reasons, 0.5 Gm. is given every 
evening to insure against sleepless¬ 
ness. If the delirium is not con¬ 
trolled from the 2 Gm. as given 
above, another gram may be given 
five to six hours after the second 
dose. Only 3 patients have failed to 
respond to this treatment out of a 
total of 100. There were 2 deaths 
from double pneumonia. In all the 
author’s experience he has only seen 
1 case of veronal rash, and abso¬ 
lutely no other symptoms of veronal 
poisoning. V. F. Moller (Berl. klin. 
Woch., Dec. 27, 1909). 

Broadbent, of London, has found very 
efficacious the following treatment of de¬ 
lirium tremens. The patient is stripped 
naked and lies on a blanket over a water¬ 
proof sheet. A copious supply of ice-cold 
water is provided, and a large bath sponge 
dripping with the iced water is dashed 
violently on the face, neck, chest, and 
body as rapidly as possible. He is then 
rubbed dry with a rough towel, and the 
process is repeated a second and a third 
time. The patient is now turned over, and 
the wet sponge is dashed on the back of 
the head and down the whole length of the 
spine two or three times, vigorous friction 
with a bath towel being employed be¬ 
tween the cold-water applications. By the 
time the patient is dried and made com¬ 
fortable, he will be fast asleep. 

Delirium tremens, on alcoholic 
basis, even in strong men of middle 
age, is a serious illness, with a mor- 


ALCOHOL (SAJOUS). 


537 


tality variously stated as 3 to 19 per 
cent. The writer treated 396 cases 
from 1901 to 1906 with chloral hydrate 
(1 to 3 grains) and with bromides. 
Digitalis was given only when neces¬ 
sary, and alcohol was withheld. The 
mortality was 9 per cent. Of the 
cases, 17.4 per cent, belonged to the 
type of delirium imminens. Between 
1907 and 1909, 264 cases were treated 
almost exclusively with veronal. The 
drug was dissolved in warm tea. 
Soon after admission the patient re¬ 
ceived 1 Gm. (15 grains), and one to 
two hours later a second gram. If 
necessary, a third gram is adminis¬ 
tered within five hours and a fourth 
gram within twelve hours. There 
never w^as the slightest untoward 
effect on pulse or respiration. The 
mortality sank to 3.4 per cent.; the 
percentage of cases where the de¬ 
lirium could be prevented rose to 28. 
The majority of fatal cases already 
suffered from pneumonia. This ob¬ 
servation proves that veronal is far 
superior to chloral and bromides to 
check the attack in its incipiency, and 
also to prevent a fatal issue. Ernst 
V. d. Porten (Therap. d. Gegenwart, 
June, 1910; Merck’s Archives, Nov., 
1910). 

Incipient cases, with insomnia, rest¬ 
lessness, tremor, occasionally hal¬ 
lucinations, should receive large doses 
of hypnotics, preferably veronal; 
whisky should be given regularly, and 
ergot at frequent intervals, either by 
intramuscular injection or by mouth. 
Discontinue medication gradually, and 
only after all restlessness and tremor 
has disappeared. More advanced 
cases, with marked delirium, inco¬ 
ordination, usually fever, slight leuco- 
cytosis, and profuse perspiration, 
should receive veronal in moderate 
doses; also ergot. Ranson and Scott 
(Amer. Jour. Med. Sci., May, 1911). 

It must not be forgotten, however, 
that large doses of narcotics, with the 
cardiac depression apt to follow their 
exhibition, are dangerous, especially 
in the aged and infirm inebriates. 
Kerr preferred repeated doses of 


liquor ammoniae acetatis (B. P.). 
Sleep, thus quietly and safely in¬ 
duced, has proved much more cura¬ 
tive than narcotics in his practice. 

Trional and opium, if given, should 
be administered cautiously. 

If fever is present, the cold douche, 
bath, or preferably the wet pack may 
be tried. If the pulse becomes too 
rapid and weak, very small doses of 
digitalis in aromatic spirit of ammo¬ 
nia should be given. Digitalis in large 
doses is dangerous (Osier, Delpeuch, 
Kerr).' 

The author witnessed the collapse 
and death of a robust man in delirium 
tremens while being given a prolonged 
warm bath. One of his patients suc¬ 
cumbed in collapse during a wet pack, 
and he has consequently abandoned 
these measures. In treatment of 1051 
cases of delirium tremens in the last 
sixteen years, he has made it a rule to 
allow no alcohol. In the first series of 
486 cases the mortality was 6.37 per 
cent., while in the last 565 cases it has 
been only 0.88 per cent. He ascribes this 
improvement in the results to his 
observation of the fact that the cause 
of death in delirium tremens is gen¬ 
erally paralysis of the heart, and he 
now addresses treatment to the heart 
regardless of whether cardiac symp¬ 
toms are apparent or not. The agita¬ 
tion and motor excitement react on 
the heart, and signs of heart weakness 
soon become manifest. He makes it a 
rule to give digitalis from the very 
first, giving 1.5 Gm. in an infusion in 
the course of the day and repeating 
this dose two or three times. If it can¬ 
not be given by the mouth, he gives it 
in a rectal injection. At the first signs 
of heart weakness other heart tonics 
are used; 1 Gm. of camphorated oil is 
injected subcutaneously every hour or 
so until the critical symptoms subside. 
A tablespoonful of ice-cold cham¬ 
pagne every half-hour was also found 
useful—the only way in which he 
allows alcohol. To promote the 
washing out of the toxins causing 


538 


ALCOHOL (SAJOUS). 


the attack, he has the patients drink 
copiously, and supplies them for the 
purpose with a drink which has the 
color of beer and tastes refreshing, 
and is taken eagerly by the delirious 
patient. It is merely a 1 per cent, 
solution of sodium acetate in water 
to which a little common syrup has 
been added. S. Ganser (Munch, med. 
Woch., Bd. liv, Nu. 3, 1907). 

The writer ascribes the symptoms 
of this condition to the accumulation 
of toxic products, autogenous as well 
as alcoholic, in the blood. Accord¬ 
ingly, he aims at the removal of these 
deleterious substances. He gives nor¬ 
mal salt solution in large quantities 
by the rectum, hypodermically, or, if 
necessary, intravenously. Thus the 
entire circulatory system is flushed 
with fluid to its utmost capacity, and 
this is then relieved by free purgation 
with large and repeated doses of 
Epsom salt. Calomel in full doses is 
also given. Sparteine is administered 
in 2-grain doses for the purpose of 
supporting the heart and promoting 
diuresis. For the delirium itself gel- 
semine is given every hour, or every 
two hours, until its physiological 
effect is produced; the dose advised 
is %5 grain. Alcohol is reduced to 
moderate limits, but is not entirely 
withdrawn: opium and other nar¬ 

cotics are condemned as not merely 
dangerous, but useless. Physical re¬ 
straint is also held to be not permis¬ 
sible. In 450 consecutive cases the 
results of this line of treatment are 
described as excellent, and no death 
from delirium tremens occurred in 
the whole series. G. E. Pettey (The 
Hospital, Jan. 15, 1910). 

The writer found that cases of 
acute alcoholic delirium of the se¬ 
verer types were suffering from acid 
intoxication. His treatment, there¬ 
fore, was directed towards efforts to 
neutralize it and to favor its rapid 
elimination. He employed a mixture 
of sodium bromide, sodium chloride, 
and sodium bicarbonate that could be 
used in large quantities intravenously 
without producing the toxic effect of 
bromide as ordinarily given in large 


doses. As the severe types also suf¬ 
fer from starvation acidosis, glucose 
in high concentration was also used 
intravenously. The solution may be 
given once a day or every 2 hours, 
according to the results obtained. In 
the cases given the blood-pressure 
was lowered after the injections. 
Any existing edema, as of the brain, 
was reduced; all the tissues of the 
body and the blood were dehydrated 
by the action of the salts. Hogan 
(Jour. Amer. Med. Assoc., Dec. 16, 
1916). 

The routine treatment for delirium 
tremens employed by the writer in 
the Cincinnati General Llospital is as 
follows: Catharsis is used as, a 

routine measure, calomel, followed 
by a rather large dose of Epsom 
salts. Tincture of digitalis and tinc¬ 
ture of nux vomica, 10 drops of each, 
are given by mouth every 3 hours. 
In the active state of delirium strych¬ 
nine and digitalin are given hypoder¬ 
mically. This stimulation is the most 
essential part of the treatment. In 
mild cases the indication for alkalies 
is met by the use of the imperial 
drink with lemon juice. Prolonged 
hot baths and hot packs are given 
twice a day, chloral and bromids are 
given only at night, and then not 
more than 2 to 3 doses during the 12 
hours. In ordinary mild cases of 
delirium tremens, uncomplicated with 
kidney trouble, the above treatment 
is sufficient and the disease runs a 
very mild course. In the more severe 
cases, and at present a routine treat¬ 
ment, spinal puncture is resorted to 
as soon as the patient begins to have 
hallucinations. From 30 to 60 c.c. 
(1 to '2 ounces) are usually with¬ 
drawn. The withdrawal of fluid is 
followed by a rapid reduction of the 
delirium especially in cases which 
have had preliminary stimulation and 
alkalinization. Hoppe (Jour. Nerv. 
and Mental Dis., Feb., 1918). 

The patient should be carefully fed, 
milk and concentrated broths being- 
especially useful. If necessary, nutri¬ 
ent enemata are to be administered. 


ALCOHOL (SAJOUS). 


539 


Excellent is hypodermoclysis or the 
intravenous infusion of saline solution 
in delirium tremens, which increase 
the amount of the circulating medium 
in which the toxic materials are dis¬ 
solved, thereby diluting the poison 
and bathing the nerve-centers with 
a more attenuated solution of the 
same. The amount of circulating fluid 
is increased above the normal, so that 
the excretion of fluids through all the 
eliminatory channels is augmented, 
thereby carrying off in solution much 
of the contained toxins. The action of 
the heart is improved by the filling of 
the relaxed vessels. These suffice to 
restore the physiological equilibrium 
and turn the balance in favor of recov¬ 
ery (Warbasse, Quenu). 

Comparison of the number of cases 
of delirium tremens and of trauma 
in drunken men during a period of 
municipal total prohibition with the 
period before it, and during a period 
of partial prohibition in that a sup¬ 
posedly prohibitive price had been 
placed on liquors. The cases of 
delirium tremens which had averaged 
5 or 6 a week, ceased totally during 
the total prohibition, but the number 
of “drunks” was even higher than 
usual, the restrictive measures evi¬ 
dently failing in their purpose. It 
takes brandy to produce delirium tre¬ 
mens, and this is scarcely obtain¬ 
able. H. I. Schou (Ugeskrift for 
Laeger, May 24, 1917). 

ACUTE ALCOHOLIC MANIA 
(MANIA A POTU). 

SYMPTOMS. — The patient, in 
a wild, ungovernable fury, shouts, 
stamps, strikes, or kicks, and is, for the 
moment, uncontrollable. The eyes roll, 
the face is flushed, and the veins dis¬ 
tended and engorged; the muscles are 
at their highest point of tension, and 
are in continuous, violent action. The 
pulse is strong, bounding, and tumultu¬ 


ous. Though mechanically conscious, 
the subject is filled with “blind fury.” 
He is carried away in a tempest of nerv¬ 
ous excitation and passion. The par¬ 
oxysms of violence sometimes last only 
a few minutes, at other times for from 
an hour to several days, with quiet 
intermissions. Rarely are there delu¬ 
sions, though the infuriated subject 
may vent his violence on the first ani¬ 
mate or inanimate object in his way. 
In a few cases the fury is directed 
against a certain person or thing. Vio¬ 
lence is succeeded by calm; a few min¬ 
utes after a storm the temperature is 
normal, and during the paroxysm 
rarely raised. In some constitutions a 
paroxysm may be provoked by a small 
quantity of alcohol (Kerr). 

DIFFERENTIAL DIAGNOSIS. 
—It may be differentiated from delir¬ 
ium tremens by the absence of tremors, 
terror, hallucinations, delusions, the 
white tongue, nausea, and the delirium 
of the latter. Further, mania a potu 
may arise from a small quantity of an 
intoxicant taken in a short time, while 
delirium tremens is due to large quan¬ 
tities taken in rapid succession, or 
from smaller quantities long continued 
(Kerr). 

ETIOLOGY AND PATHOL¬ 
OGY.—Mania a potu is occasionally 
seen in chronic inebriates, and most 
frequently in periodic tipplers. In the 
latter it often occurs when, after an 
interval of abstinence, an intoxicant 
is freely partaken of. .Some chronic 
inebriates invariably suffer acute mania 
if they drink a single glass of spirits, 
wine, or beer beyond their usual allow¬ 
ance. 

The paroxysms of acute mania 
resemble those of epilepsy, and a large 
proportion of police-court drunken of¬ 
fenders are patients of this class. The 


540 


ALOES (SAJOUS). 


symptoms are evoked by the patho¬ 
logical action of acute alcoholic in¬ 
toxication on nervous systems liable 
to such excitation, either congenitally 
or from the effects of intemperance, 
traumatism, or brain-tire. According 
to Jones, the forms of insanity met 
with which result from alcoholism 
are: 1, amnesic; 2, delusional and, 3, 
chronic varieties which end in de¬ 
mentia. 

PROGNOSIS. — The prognosis is 
much more favorable than in ordinary 
acute mania, the paroxysm usually 
rapidly passing away, leaving the pa¬ 
tient exhausted and peaceful. Unless 
alcohol be taken again relapse is rare. 

TREATMENT. —But little treat¬ 
ment is generally needed in this con¬ 
dition. Non-alcoholic liquids, such as 
milk, iced milk, milk and soda, or 
saline draughts with ipecacuanha and 
bromides are sufficient to bring about 
recovery. Sometimes cold affusions 
and, in prolonged paroxysms, wet 
packs prove valuable adjuncts. 

When violent mania is present, apo- 
morphine, % to % grain, hypodermic¬ 
ally, causes nausea and rapid sedation. 

If it persists, potassium bromide, in 
30-grain doses every two hours, or 
morphine, 44 grain at long intervals, 
must be resorted to. 

C. E. DE M. Sajous 

AND 

L. T. DE M. Sajous, 
Philadelphia. 

ALEPPO BOIL. See Oriental 
Sore. 

ALOES {Aloe). —The inspissated 
juice of the leaves of Aloe vera or 
A. chinensis (Curasao or Barbadoes 
aloes) or of other species, such as Aloe 
Perryi (socotrine aloes. East Africa) 
and Aloe spicata or A. ferox (Cape 


aloes). The plants are indigenous in 
Africa and India, and are naturalized 
in the West Indies and along the Med¬ 
iterranean shores. 

PROPERTIES AND CONSTIT¬ 
UENTS. —Curagao aloes occurs in 
orange-brown, opaque, and resin-like 
masses which give off an odor of saf¬ 
fron and have a very bitter and some¬ 
what nauseous taste. Socotrine aloes 
varies in color from yellowish brown 
to dark brown; its odor and taste are 
similar to those of Barbadoes aloes. 
Cape aloes is reddish brown or olive- 
black. 

According to A. R. L. Dohme, 
Curagao aloes is as efficient as socotrine 
aloes and less expensive; the greater 
portion of the latter now sold is made 
up of the former. 

Purified -aloes {aloe purificata), the 
form generally employed in medicine, 
is aloes which has been softened by 
heating and the addition of alcohol, 
strained, and dried. It occurs in com¬ 
merce in pieces or in powder form. 

Aloes contains: 1. Aloin, a bitter, 
crystalline principle present in amounts 
ranging from 4 to 30 per cent., and 
composed in socotrine aloes exclusively 
of barbaloin, to which, in Curagao 
aloes, is added the isomeric body iso- 
barbaloin. 2. Emodin (Kraemer), an 
actively cathartic principle. 3. A yel¬ 
lowish, odoriferous volatile oil. 4. A 
resinous material, varying according to 
the species of aloes. 5. Albuminous 
bodies. 6. Fatty substances. 7. A 
small amount of gallic acid. 

Aloin, official as Aloinum, occurs as 
minute orange-colored crystals or as 
a microcrystalline powder varying in 
color from lemon-yellow to yellowish 
brown. It has little or no odor, is bitter 
to the taste, and remains unchanged in 
the air. It is soluble in 65 parts of 


ALOES (SAJOUS). 


541 


water and in 10.75 parts of alcohol. Its 
solutions turn brown on continued ex¬ 
posure, and when alkalies are added 
present a dark-red color with greenish 
fluorescence. 

DOSE AND PREPARATIONS. 

—the dose of purified aloes in adults 
is % to 10 grains (0.03 to 0.6 Gm.), 
the average dose being officially given 
as 4 grains (0.25 Gm.). The dose of 
aloin is % to 2 grains (0.03 to 0.12 
Gm.). Average dose: 1 grain (0.065 
Gm.). The other official or semi-offi¬ 
cial preparations of aloes are:— 

Pilula Aloes, containing aloes and 
soap, of each, 2 grains (0.13 Gm.). 
Dose: 1 to 4 pills. 

Tinctura Aloes (10 per cent.), con¬ 
taining also 20 per cent, of licorice. 
Dose: % to 1 fluidram (1 to 4 c.c.). 
Average dose: 30 minims (2 c.c.). 

Extractum Aloes, N. F.—A watery 
extract, dried and powdered. Dose: 3/2 
to 6 grains (0.03 to 0.4 Gm.). Aver¬ 
age dose: 2 grains (0.125 Gm.). 

Pilula Aloes et Ferri, N. F., contain¬ 
ing purified aloes, dried ferrous sul¬ 
phate, confection of rose, and aromatic 
powder, of each, 1 grain (0.07 Gm.). 
Dose: 1 to 4 pills. 

Pilula Aloes et Mastiches, N. F., 
(Lady Webster’s Dinner Pill), contain¬ 
ing purified aloes, 2 grains (0.13 Gm.) ; 
mastic, % grain (0.04 Gm.), and pow¬ 
dered red rose, % grain (0.03 Gm.). 
Dose: 1 to 4 pills. 

Pilula Aloes et Myrrhcc, N. F., con¬ 
taining purified aloes, 2 grains (0.13 
Gm.) ; myrrh, 1 grain (0.07 Gm.), and 
aromatic powder, % grain (0.04 Gm.). 
Dose: 1 to 4 pills. 

Tinctura Aloes et Myrrhcc, N. F., 
containing aloes, myrrh, and licorice, 
of each, 10 per cent. Average dose: 
30 minims (2 c.c.). 

Aloes is also a constituent of:— 


Tinctura Benzoini Composita,co\\VAm- 
ing benzoin, 10 parts; aloes, 2; storax, 
8; tolu, 4. Dose: 30 minims (2 c.c.). 

Extractum Colocynthidis Composi- 
tuni, containing extract of colocynth, 
16 parts; purified aloes, 50; resin of 
scammony and powdered soap, of each, 
14; cardamom, 6. Dose: 7 lA grains 
(0.5 Gm.). 

Pilula cathartica composita. 

Ext. colocynthidis 

comp .gr. il^ (0.08 Gm.). 

Hydrarg. chloridi 

mitis . gr. j (0.06 Gm.). 

Resince jalapcc .. gr. % (0.02 Gm.). 

Cambogice pul- 

veris . gr. 14 (0.015 Gm.). 

Dose: 2 pills. 

Pilula rhei composita. 

Rhei pulveris ... gr. ij (0.13 Gm.). 

Aloes . gr. iss (0.10 Gm.). 

Myrrhce . gr. j (0.06 Gm.). 

Olei menthce pip., gr. (0.005 Gm.). 

Dose: 2 pills. 

Pilula cathartica vegetabilis, N. F. 

Ext. colocynthidis 

comp .. gr. j (0.06 Gm.). 

Ext. hyoscyami . gr. ss (0.03 Gm.). 

Resince jalapce .. gr. 14 (0.02 Gm.). 

Ext. leptandree, 

Resince podo- 

phylli .aa gr. % (0.015 Gm.). 

Olei menthce 

piperitce . gr. ^ (0.008 Gm.). 

Dose: 2 pills. 

Pilula laxativa composita, N. F. 

n Aloini .. gr. 14 (0.013 Gm.). 

Strychnince . gr. 14.28 (0.0005 Gm.). 

Ext. belladonnce 

fol . gr. 14 (0.008 Gm.). 

ipecacuanhee pulv. gr. He (0.004 Gm.). 

Glycyrrhizce pulv. gr. ^ (0.046 Gm.). 

Dose: 2 pills. 

MODES OF ADMINISTRA¬ 
TION. —Aloes is entirely soluble in 
5 parts of alcohol, but only partly sol¬ 
uble in water. It is generally admin¬ 
istered in pill form on account of its 
strongly bitter taste. It acts slowly, 
and can, therefore, be administered at 
bedtime with the expectation that its 
effects will be exerted the next morn¬ 
ing. Aloes may be used alone, but is 
oftener given in conjunction with other 













542 


ALOES (SAJOUS). 


cathartic remedies and correctives, as 
in several of the preparations above 
mentioned. Certain agents have been 
found to increase its effects, including 
bile, iron, and the alkalies. Equal parts 
of purified aloes and dried oxgall may 
be administered in a salol-coated pill 
with advantage. Aloin, while somewhat 
less certain in its action than aloes, is 
often considered preferable because of 
the smaller dose required and less lia¬ 
bility to cause “griping.” It is fre¬ 
quently employed in the aloin, bella¬ 
donna, and strychnine pills, of which 
the official form {Piliila Laxativa 
Comp.) has already been referred to. 

INCOMPATIBLES.—Aloes is in¬ 
compatible with mineral acids, iodine, 
silver nitrate, tannic acid, phenol, men¬ 
thol, thymol, and salicylic acid. 

CONTRAINDICATIONS. —It is 

generally inadvisable to prescribe aloes 
in cases of hemorrhoids, owing to its 
effect of causing congestion of the pel¬ 
vic organs; in cases accompanied by 
free secretion of mucous in the bowel, 
however, it may, on the contrary, prove 
beneficial. Aloes is likewise contrain¬ 
dicated in pregnancy and in menorrha¬ 
gia occurring in plethoric women. In 
view of its elimination, in part, through 
the milk, it is not available for use as 
a purgative in nursing women. 

PHYSIOLOGICAL ACTION.— 
In small doses aloes and aloin exert a 
stomachic effect. The secretions of the 
alimentary tract are augmented. With 
larger doses (2 to 4 grains) its well- 
known laxative effect is obtained, ten 
to fifteen hours usually elapsing from 
the moment of extubation until the first 
evacuation results. The effect is due 
to stimulation of the muscular coat as 
well as the glands of the large intestine, 
and is generally attended with a cer¬ 
tain amount of griping pain. Through 


its property of inducing hyperemia in 
the ovaries and uterus, aloes also has 
distinct value as an cmmenagogiie. 

Though easily absorbed through 
abrasions and ulcerated areas (exercis¬ 
ing thereafter its characteristic laxative 
and other effects), aloes exerts no local 
therapeutic action. It is eliminated with 
the feces, slightly with the urine, and, 
in nursing women, with the mammary 
secretion. 

Aloin, the so-called active principle 
of aloes, is believed not to exert its ef¬ 
fect in the bowel until it has undergone 
certain changes in composition. The 
resulting active compound, which can 
be made from the pure, crystalline aloin 
by boiling a solution of the latter 
(Cushny), is probably contained in the 
crude drug after the crystalline aloin 
has been extracted. Hence, the fact 
that in practice crude aloes is found 
to act with greater certainty and speed 
than the principle aloin. It has been 
found that in human beings placed 
upon an exclusive meat diet aloin acts 
much more strongly than in persons 
subsisting on a mixed diet. The aloin 
is believed to be altered through proc¬ 
esses of hydrolysis and oxidation into 
emodih (oxymethylanthraquinone), an 
active constituent of many other drugs 
of this class, such as senna, cascara 
sagrada, and rhubarb, which induces 
the purgative effect. Injected under 
the skin or into a vein, aloin for the 
most part passes into the bowel, there 
exerting an irritant effect and inducing 
purgation. In the rabbit, however, in 
which aloin is excreted to a large ex¬ 
tent through the kidneys, pronounced 
irritation of these organs is produced, 
catharsis being, on the other hand, an 
infrequent result. A nephritis is gen¬ 
erally induced, in which the epithelium 
of the tubules is particularly involved, 


ALOES (SAJOUS). 


543 


the glomeruli being largely spared. The 
urine contains casts, blood, proteids, 
and leucocytes; it may be either aug¬ 
mented or decreased in quantity (Miir- 
set). 

UNTOWARD EFFECTS.—The 

use of aloes over long periods is said 
to favor the production of hemor¬ 
rhoids. Large doses of aloes induce 
burning at the anus; sometimes blood- 
stained stools, painful micturition, 
and uterine discomfort. Dosage ex¬ 
ceeding 0.20 Gm. (3 grains) per diem, 
when persisted in for any length of 
time, leads inevitably to intesitinal 
irritation and congestion (Pouchet). 
Massive single doses of aloes may in¬ 
duce general prostration with slowing 
of the pulse and a fall in the tempera¬ 
ture. 

THERAPEUTIC USES. —As a 
Laxative.—Aloes is most frequently 
used in the treatment of constipation 
due to intestinal atony. In moderate 
doses it stimulates the intestinal mu¬ 
cosa to increased secretory activity, 
thereby facilitating the discharge of the 
bowel contents. Its continued use is, 
however, to be avoided, since on pro¬ 
longed administration a tendency to 
aggravation of the disorder present is 
likely to appear. 

A characteristic feature of the ac¬ 
tion of aloes is the congestion it tends 
to produce in the intestinal tract (es¬ 
pecially the rectum) and pelvic organs. 
This property has led to its occasional 
use as a derivative in conditions asso¬ 
ciated with cerebral or pulmonary con¬ 
gestion, blood being thereby removed 
from the engorged area. Experimental 
work has shown that aloes, in common 
with other purgatives of the anthracene 
series, does not act as a true chola- 
gogue, i.e., does not increase the amount 
and concentration of the biliary secre¬ 


tion. It does, however, by accelerating 
peristalsis, promote the removal of bile 
from the intestinal tract, and prevent 
Its reabsorption from the duodenum 
into the liver. For the relief of hepatic 
congestion, Rendu has recommended 
the use of aloes in combination with 
calomel and gamboge. The cathartic 
effect of aloes has been found to be 
greatly favored by the presence of bile, 
which is believed to assist by exerting 
a solvent action on the drug, thereby 
hastening its effect. In view of this 
observation, too, it is thought that in 
cases of obstructive jaundice the action 
of aloes is interfered with owing to the 
deficiency of bile. 

Alkalies and iron assist the purgative 
action of aloes. The former facilitate 
the decomposition of aloin, whereby a 
more strongly irritant and cathartic 
substance is formed. Iron similarly' 
favors the oxidation of aloin. In chlo¬ 
rosis the aloes and iron combination is 
often employed, as in the official pill 
of aloes and iron. It is best, however, 
not to use this pill, owing to .the par¬ 
ticularly marked constipating effect of 
the preparation of iron it contains. The 
pyrophosphate of iron or dialyzed iron 
is to be preferred. Nux vomica and 
belladonna, or their active alkaloids, 
are also frequently combined with 
aloes, the former to improve the tone 
of the intestinal muscles, and the latter 
to prevent “griping.” The last-named 
effect can also be minimized by giving 
the drug after meals. 

Robin recommends the following 
pill as a mild, but efficient laxative:— 

R Aloes, 

Ext. of liquorice ..aa 1 gr. (0.06 Gm.). 

Gamboge . K gr. (0.03 Gm.). 

Ext. of belladonna, 

Ext.ofhyoscyamus,aa 1 gr. (0.06 Gm.). 

Enough for 1 pill. Take one or two on 
retiring. 



544 


ALOPECIA (SCHAMBERG). 


Aloin possesses over crude aloes the 
advantages of smaller bulk and less 
tendency to cause intestinal irritation, 
but these are partly offset by the dimin¬ 
ished certainty and celerity of its action. 

In large doses aloes acts as a drastic, 
inducing first eructations and a feeling 
of weight in the stomach, then copious 
stools with colicky pains. Its use as 
such, however, is to be avoided, because 
of the marked intestinal irritation and 
congestion it causes. 

As a Stomachic.—In doses not ex¬ 
ceeding 1 to grains (0.06 to 0.10 
Gm.) daily, aloes improves the appe¬ 
tite and excites the gastric functions. 

As an Emmenagogue.—In anemic 
women with amenorrhea aloes is 
sometimes given to favor the men¬ 
strual flow. It is best given four days 
before the expected period, and its 
action is greatly enhanced by combi¬ 
nation with iron. In amenorrhea due 
to other causes the official pill of 
aloes and myrrh may be tried, the 
congestive influence of the active drug 
tending , to facilitate menstruation; 
good results, however, follow less often 
than in the anemic cases. 

In Hemorrhoids.—Though the use 
of aloes as a laxative is contraindicated 
in the presence of hemorrhoids, this 
drug, given in small doses, has been 
claimed by some to be beneficial in 
cases where the circulation in the in¬ 
ferior hemorrhoidal veins is particu¬ 
larly sluggish and the pile masses 
protrude, inducing tenesmus. The use 
of aloes in very small doses when hem¬ 
orrhoids are associated with irritation 
and frequent small, thin evacuations 
has been advocated by Fordyce Barker. 

C. E. DE M. Sajous 

AND 

L. T. DE M. Sajous, 
Philadelphia. 


ALOPECIA. —Baldness; calvities. 

DEFINITION. — Alopecia is a 
physiological or pathological deficiency 
or loss of hair, either partial or com¬ 
plete. The forms of alopecia may be 
classified as shown on opposite page. 

Congenital Alopecia.—This com¬ 
monly manifests itself either as. a scanty 
growth, a development only in certain 
localities, or as a retarded appearance 
of the hair. In rare cases there may be 
complete absence of the hair due to 
arrested development of the follicles. 
In such cases hereditary predisposition 
is usually present, and there are apt to 
be, in addition, delayed or defective 
dentition, and at times developmental 
defects of the nails. 

[J. H. Hill (Brit. Med. Jour., vol. i, 1881, 
page 177) has described a race of hairless 
Australian aborigines. Jay F. Schamberg.] 

Case of hereditary alopecia due to 
hypothyroidia, occurring in 3 gener¬ 
ations, affecting equally the male and 
female members of the family, and 
limited strictly to the scalp. The 
affected individuals were born with a 
normal growth of hair which con¬ 
tinued to grow normally until about 
the fourth or sixth year. It then be¬ 
gan to fall out and lose its pigment, 
becoming completely colorless, and 
continued to do so until at puberty 
or a little later the scalp was com¬ 
pletely bald. In 3 children of the 
family under observation the ad¬ 
ministration of thyreoidin, in doses 
of K to IH grains (0.03 to 0.09 Gm.) 
daily, was followed by good results. 
Petersen (Dermat. Zeitsch., Apr., 
1915). 

A diminution or absence of the se¬ 
cretion of the thyroid gland is known 
to cause the following changes in the 
skin; Myxedema, roughness and 
dryness of the skin; yellow com¬ 
plexion with a rather circumscribed 
redness of the cheeks, called the 
malar flush”; dry seborrheic coating 
of the scalp, constituting at times a 
thick crust; dryness, lack of luster 


ALOPECIA (SCllAMLELG). 
I'oRMs OK Alopecia. 


545 


I. Congenital alopecia. 
II. Senile alopecia. 


(a) Idiopathic. 


III. Premature 
alopecia. 


(b) Symptomatic. 


Hereditary predis¬ 
position. 


(1) Local diseases. 


(2) General 
eases. 


dis- 


Seborrhea. 

Eczema seborrhoicum. 
Psoriasis. 

Erysipelas. 

Lupus erythematosus. 

Syphilodermata. 

Folliculitis. 

Tinea tonsurans. 

Tinea favosa, etc. 

Typhoid fever. 
Acute Variola. 

Scarlatina. 
Pregnancy. 


Syphilis. 

Leprosy. 

Myxedema. 

Neurasthenia. 

Chronic intoxications 
Anemia. 

Diabetes. 

Cancer. 

Uric acid diathesis. 
Phthisis, etc. 


Chronic 


and wiriness and defluvium of the 
hair. He cites a personal case in 
which progressive alopecia yielded 
rapidly under a careful diet and 5 
grains (0.3 Gm.) of thyroid gland a 
day. Montgomery (Jour. Cutan. 
Dis., Apr., 1915). 

Its really important and striking 
features, based on a careful study of 
serial sections from different parts 
of the skin of a case were the fol¬ 
lowing: there were comparatively 

few vessels; there was 1 arrector pili 
muscle; 1 abortive follicle; no hair 
shaft; no sebaceous glands; and no 
sweat glands. Blaisdell, Cunning¬ 
ham and White (Boston Med. and 
Surg. Jour., Feb. 8, 1917). 

Senile Alopecia.—As the name indi¬ 
cates, this form of baldness is observed 
in the aged. With the atrophic skin 
changes that accompany senility there 

takes place a gradual thinning of the 

1 - 


hair, beginning upon the vertex of the 
scalp, the frontal and the temporal 
regions, and slowly leading to a more 
or less complete baldness of the cal¬ 
varium. Under the microscope the 
cutis proper and the hypoderm exhibit 
thinning and atrophy. 

Case of periodical shedding of the 
hair in a woman aged 21 years. Her 
hair was shed every winter and grew 
in again in the summer. Last winter 
she became entirely bald, and this sum¬ 
mer her hair did not grow in again. 
Absence of hair existed on the general 
surface, which began in circular patches 
when she was 12 years old. H. Leder- 
mann (Jour, of Cut. Dis., Jan., 1904). 

Premature Alopecia.—This form of 
alopecia is encountered chiefly in in¬ 
dividuals between the ages of 20 and 
35. G. T. Elliott found that among 344 

-35 









.546 


ALOPECIA (SCHAMBERG). 


private cases of premature alopecia, 64 
per cent, occurred under the age of 30. 
Premature alopecia may be either idio¬ 
pathic or symptomatic. 

In the idiopathic variety the scalp 
presents no abnormal condition. At 
first only a few hairs fall out from 
time to time, being replaced by a shorter 
or finer growth. Later these fall and 
are followed by still finer hairs. In this 
manner the greater part of the hair of 
the scalp may be gradually lost. The 
affection occurs in both sexes, although 
much less frequently and less com¬ 
pletely in women than in men. Heredity 
appears to be a strong predisposing 
factor. 

There is a growing opinion that the 
so-called idiopathic baldness is excep¬ 
tional, and that most cases of premature 
alopecia are associated with seborrhea 
in some form. Of 344 private cases of 
premature alopecia studied by Elliott, 
316 had seborrhea. Jackson found 75 
per cent, of 300 cases due to seborrhea. 

The symptomatic form results from 
various local and general diseases. 
Rapid falling of the hair (defluvium 
capillorum) commonly follows acute 
diseases, such as typhoid fever, small¬ 
pox, etc. Full regeneration of the 
hair follows the restoration to health. 
Rapid and extensive loss of hair 
occurs with frequency in the early 
stages of syphilis. The hair is also 
thinned or lost in such cachectic condi¬ 
tions as phthisis, myxedema, diabetes 
mellitus, leprosy, etc. 

Referring to the fall of the hair 
after influenza, the writer points out 
that the temples and occiput are the 
areas usually chiefly affected. He at¬ 
tributes it to the toxemia, and thinks 
probably it is indirectly due to the 
toxemia affecting the trophic nerves 
to certain areas of the scalp. He does 
not recommend cutting the hair un¬ 


less that is necessary to carry out 
any special form of treatment. A. 
Pasini (Giorn. Ital. d. Mai. Ven. e 
delle Pelle, fasc. i, 53, 1919). 

Alopecia Seborrhoeica. — Consider¬ 
able difference of opinion exists as to 
what constitutes the seborrheic proc¬ 
ess; the comprehension of the relation 
of seborrhea to baldness is thereby 
embarrassed. Nearly all writers are 
agreed that dandruff has not the same 
significance for all observers. Sabour- 
aud holds that dry pityriasis of the 
scalp is not a depilating affection 
itself, but that it is frequently asso¬ 
ciated with the true seborrhea. Many 
clinicians speak of an alopecia pityrodes 
in which there is either a seborrhea 
with fatty crusts or a pityriasis with 
abundant scaling. Crocker does not 
restrict alopecia seborrhoeica to the 
oily form: according to his experience 
there is either “an excessive greasi¬ 
ness of the surface from oily sebor¬ 
rhea, or fine, glistening, powdery 
scales, or greasy scales lying closely 
on the scalp and requiring to be 
scraped off, or yellowish, fatty matter 
looking like pale-yellow wax.” 

New clinical form of atrophic alo¬ 
pecia, for which the term “pseudo¬ 
pelade” is adopted. It is a process of 
atrophy and sclerosis affecting the hair- 
covered regions of the body, especially 
the scalp, terminating in patches of 
baldness, smooth, of pseudocicatricial 
aspect. It seems to be closely allied to 
erythematous lupus and keratosis pilaris. 
Brocq, Lenglet, and Ayrignac (Annales 
de dermat., vol. i, No. 3, 1905). 

Analysis of 679 cases of loss of hair, 
chiefly alopecia simplex and alopecia 
furfuracea. There were, however, 86 
cases of alopecia and lesser numbers 
due to ringworm and syphilis, and 2 
cases from X-rays. Women seemed to 
be more affected by loss of hair, in the 
relative proportion of 54 to 46, but 
possibly they consult physicians more 
freely on this account than do men. 


ALOPECIA (SCHAMBERG). 


547 


The author finds that heredity, dan¬ 
druff, systemic depression, fever, opera¬ 
tions and maltreatment of the scalp 
have been connected iti the patients’ 
minds with the fall of hair and, accord¬ 
ing to his figures, hereditary taint ex¬ 
ists in 30 per cent, while dandruff was 
present in 443 patients, a percentage 
of more than 79. Systemic depression 
was recorded in 120 cases, fever in 63, 
and maltreatment was evident in 277 
cases, or nearly half of the whole num¬ 
ber. Most patients were unable to re¬ 
member the date of beginning alopecia, 
but it seems, from all the accurate 
data that could be obtained, that in the 
clinically uncomplicated loss of hair, 
it began before 30 in 84 per cent, of 
the males. In females it appeared at 
this early age in a much less percentage 
and seemed to be of fater development. 
Dandruff appeared also earlier in men 
than in women, being about twice as 
frequent between the ages of 16 and 
25. C. J. White (Jour. Amer. Med. 
Assoc., Sept. 24, 1910). 

ETIOLOGY AND PATHOLOGY. 

—Dandruff is generally regarded as 
the most potent cause of baldness. It 
is a plausible and attractive theory 
to attribute the process to microbic 
invasion. Sabouraud has brought 
forth strong evidence to show that 
his microbacillus is intimately asso¬ 
ciated with, if not the cause of, oily 
seborrhea. He likewise regards this 
organism as the cause of baldness. 
The microbacillus, according to him, 
enters the mouth of the hair follicle, 
multiplies, and forms a thin microbic 
lamina, which separates the hair shaft 
from the follicular wall. Epithelial 
irritation causes the encysting of the 
bacilli in a plug or cocoon. Then 
follows increased sebaceous flow, 
hypertrophy of the sebaceous gland, 
and progressive atrophy of the hair 
papillae. Sabouraud recognizes other 
causes which render the soil favor¬ 
able, such as city life, insufficient 


exercise, excessive meat diet, gout, 
heredity, etc. If baldness has a mi¬ 
crobic origin, Sabouraud is certainly 
correct in regarding the above causes— 
causes which are operative in the busy 
life of great cities—as of vast impor¬ 
tance. Premature baldness is rare or 
absent among savages and is less com¬ 
mon in country than in city districts. 

Many other factors have been in¬ 
voked as causes of baldness, such as 



Alopecia from a cured tinea favosa. (Schamberg .) 


the too frequent wetting of the hair, 
the wearing of stiff hats which con¬ 
strict the temporal arteries, etc. It is 
also stated that brain workers are 
particularly subject to premature alo¬ 
pecia; this is probably more the result 
of sedentary life than of intellectual 
activity. 

Alopecia areata is often caused by 
traumatisms of the head. The exist¬ 
ence of anatomical and functional 
lesions of the central nervous system 
must be admitted, the state of central 
irritation giving rise to peripheral 






548 


ALOPECIA (SCIIAMRERG). 


trophic disturbances, which manifest 
themselves by the appearance of hy- 
peralgesic zones. Possibly, vascular 
lesions analogous with arteriosclerosis 
are the cause of the falling out of the 
hair. At any rate, the nervous lesion 
is the predominant etiological factor. 
Psychic traumatism, especially fright, 
has an identical effect. Weichselmann 
(Deut. med. Woch., Nov. 12, 1908). 

Alopecia of dental origin often fol¬ 
lows a painful attack of trigeminal 
neuralgia caused by the teeth (18 out 
of 25 cases). This attack may pre¬ 
cede the depilation by two or three 
months, but more commonly it occurs 
in the preceding month. It occurs on 
the same side as the trigeminal attack, 
more frequently on the left side be¬ 
cause dental lesions are more common 
on the left side. It appears by pref¬ 
erence in certain predisposed zones, as 
if there was a relation between the 
seat of the dental irritation and the 
seat of the initial area of alopecia. 
Thus, in 16 cases of trouble with the 
lower wisdom tooth the author found 
alopecia localized on the same side of 
the nucha in 14. It follows alveolar 
and gingival irritation rather than den¬ 
tal irritation proper. Thus, in 25 cases 
of dental alopecia the author traced 
the cause in 3 cases to inflammation of 
the dental pulp, in the remaining 22 to 
troubles outside the teeth. These irri¬ 
tations seem to act differently upon the 
trigeminus. It is accompanied by cer¬ 
tain phenomena, such as hyperesthesia, 
erythrosis, hyperthermia, adenopathy, 
lymphangeitis, and edema, grouped by 
Jacquet under the name of the dental 
syndrome. The areas are generally 
small in size and few in number. The 
prognosis is good. The cure is rapid 
and often immediate after dental in¬ 
tervention alone. Rousscau-Decelle 
(Presse med., Feb. 6, 1909). 

Many cases of hereditary syphilis 
show no sign beyond defects of den¬ 
tition—defects which, in spite of the 
now 25-years old teaching of Four¬ 
nier, are not yet, he says, sufficiently 
well known. The writer thinks it 
hardly conceivable that the teeth in 
these cases can have suffered with¬ 


out some imprint of the disease upon 
the viscera, nervous system, or bony 
structures. Such imprint does occur, 
and it renders the offspring of 
syphilitic parents more predisposed 
to attacks from other diseases, such 
as eczema, psoriasis, and alopecia 
areata, as regards the skin, and to 
tuberculosis, enteritis, and probably 
other internal diseases. Sabouraud 
(Presse Med., Mar. 22; May 17, 1917). 

PROGNOSIS. — Alopecia sebor- 
rhceica gradually progresses, unless 
checked by treatment, to a denudation 
of the vertex leaving a fringe of hair 
in the temporal and occipital regions. 
Appropriate treatment, particularly if 
instituted early, will sometimes check 
the hair loss and lead perhaps to some 
regrowth. If systemic conditions are 
present which render the scalp a favor¬ 
able nidus, the outlook is more un¬ 
favorable. 

TREATMENT. — The treatment 
must be directed toward the existing 
seborrheic process. The measures em¬ 
ployed relate both to general and local 
treatment. Outdoor life, exposure of 
the scalp to sunlight, the restricted 
use of meats (Sabouraud says bald¬ 
ness is less common in vegetarians), 
the avoidance of excesses of all kinds, 
are to be recommended. 

Such tonics as iron, strychnine, 
phosphorus, arsenic, and codliver oil 
may be given with advantage. 

Local treatment is of great impor¬ 
tance, particularly when dandruff is 
present. It consists of the proper 
cleansing of the scalp and the stimula¬ 
tion of the sebaceous glands to healthy 
action. 

The tincture of green soap makes an 
admirable shampoo for the removal of 
epithelial and sebaceous debris. This 
may be advantageously followed by 
such a hair-wash as:— 


ALOPECIA (SCHAMBERG). 


549 


H Resorcinolis _ 3ij (8 Gm.). 

Acidi acetici ... {3j-f3ij (4-8 c.c.). 

01. ricini . f3ss-f3j (2-4 c.c.). 

Alcoholis, q. s. ad fSvj (180 c.c.). 

01. bergamott... (2.4 c.c.). 

When greater stimulation is desired, 
the following lotion may be used:— 

B Hydrarg. chlor. 

corros. ...... gr. viij (0.5 Gm.). 

Betanaphtholis . gr. xxv (1.6 Gm.). 

Glycerini . f3j (4 c.c.). 

Alcoholis . fSiv (120 c.c.). 

AqtuF cologni- 

ensis . fSss (15 c.c.). 

Aqucc . fSiiss (75 c.c.). 

Sig.: Hair-wash; part the hair and apply 
with a small sponge. 

Another lotion frequently prescribed 
where stimulation is desired is as 
follows:— 

B Tinct. canthar- 

idis . fSvj (24 c.c.). 

Tinct. capsid, 

Old ricini _aa •rTLxxx-f3j (2-4 c.c.). 

Spts. myrcioc (bay 

rum), q. s. ad fSvj (180 c.c.). 

It is a good plan in many cases to use 
an ointment in conjunction with hair 
lotions. The lotion may be used each 
day, and the pomade applied once or 
twice a week. The latter should be 
rubbed in in very small quantities, so as 
to avoid disagreeable greasing of the 
hair. When ointments are used con¬ 
jointly with washes, the glycerin or 
oil in the lotion may sometimes be ad¬ 
vantageously omitted. Sulphur is the 
most useful agent for scalp pomades 
when any seborrhea is present. The 
following ointment gives most satisfac¬ 
tory results:— 

B Sulph. prcccip .5j (4 Gm.). 

Adipis . 5j (31 Gm.). 

01. bergamott . -nxxl (2.4 c.c.). 

Daily digital massage of the scalp 
is distinctly useful, as is also the vig¬ 
orous use of the hairbrush to produce 
hyperemia of the scalp. 

Successful treatment depends upon 
the promptness with which one first 
notices that the hair is beginning to 
fall. Healthy hairs do not come out, 


and if hairs are found on the pillow, 
on the clothing, or in the hairbrush, the 
indication is given for beginning the 
treatment. One of the most important 
yet very genera^lly neglected, prophylac¬ 
tic measures consists in frequent ablu¬ 
tion of the head, a measure that is 
still considered injurious by many 
people. On the contrary, frequent 
shampooing and rubbing of the head 
is the best preventive of baldness. 
Another feature on which the author 
lays much stress is the necessity for 
cleanliness in all utensils used in the 
barber shop or in private. 

Actual baldness cannot be cured, but 
a great deal can be done to prevent its 
onset by properly treating the tendency 
to falling of the hair. A course of 
treatment is outlined, of which the fol¬ 
lowing are the most important features : 
Daily shampooing with soap and hot 
water, followed by drying and the ap¬ 
plication of a 1:1000 solution of bi¬ 
chloride of mercury. This is allowed 
to evaporate, and the scalp is then 
rubbed with a 1:400 solution of 
thymol or naphthol in alcohol. Fi¬ 
nally, an ointment is applied contain¬ 
ing 1 part of salicylic acid, 2 of tinc¬ 
ture of benzoin, and 50 of vaselin. In 
obstinate cases the treatment is be¬ 
gun by the application of tar liniment, 
which is removed ten minutes later 
with the soap. Lassar (Deut. med. 
Woch., July 5, 1906). 

The most satisfactory lubricant is 
cocoanut oil. It keeps the hair soft 
and silky and does not mat the hair 
or plaster it down. A good shampoo 
about once a month suffices. The 
wire brush keeps the scalp pretty 
free from dirt and dandruff. By its 
gentle and not disagreeable friction 
of the scalp, it promotes the circula¬ 
tion and thus brings nourishment to 
the hair-bulbs, and gives vigor to the 
growing hair. S. Hendrickson (Jour. 
Amer. Med. Assoc., Sept. 2, 1911). 

The writer considers local treat¬ 
ment of paramount importance, and 
the first part is the same for all 
forms of seborrhea. It is necessary 
first of all to remove from the scalp 
the scurf or any greasy scales that 












550 


ALOPECIA (SCHAMBERG). 


may be present, as they tend to block 
the mouths of the hair follicles and 
provide a favorable soil for bacterial 
growth. During the first month of 
treatment the head should be fre¬ 
quently washed and anointed daily 
with an antiseptic ointment. The 
head should be shampooed every eve¬ 
ning with a spirit soap lotion and 
then, after the hair has been thor¬ 
oughly dried, the following ointment 
is rubbed carefully into the entire 
surface of the scalp: 

Acidi salicylici. gr. x (0.65 Gm.). 

Sulphuris pr<u- 

cipitati .gr. xxx (2 Gm.). 

Old roscc . Tn ij (0.13 Gm.). 

Adi pis benzo- 

. 5j (30 Gm.). 

Misce. Ft. unguentum. 

Drugs that should never be used 
when the hair is light or gray are: 
Resorcin, beta naphthol, empyro- 
form, oil of cade, ichthyol, thiol, and 
tannic acid. Freshwater (Pract., Oct., 
1913). 

The frequency with which the scalp 
should he washed depends entirely upon 
the degree of oiliness of the scalp and 
hair. A greasy scalp requires more fre¬ 
quent cleansing than a dry one. .In a 
general way it may be said that the 
scalp should be washed about once in 
two or three weeks. If the skin is very 
dry afterward, a pomade should be 
employed. Soaps containing sulphur 
and tar are useful. Some of the Ger¬ 
man superfatted soaps, especially one 
containing sulphur, salicylic acid, and 
resorcin, are particularly eligible for 
the purpose. 

The drugs most successful in treat¬ 
ing loss of hair are euresol, bichloride 
of mercury, captol and chloral hy¬ 
drate. Temporarily one may expect 
good or very good response in 48 
per cent, of men and in 56 per cent, 
of women. C. J. White (Jour. Amer. 
Med. Assoc., Sept. 24, 1910). 

In premature baldness, massage of 
the scalp should be frequently and 


thoroughly done, for 20 or 30 min¬ 
utes at a time. The masseur should 
use an emollient cream, such as: 

IJ CcrcB alba ... 3vj (24 Gm.). 

Petrold . 5v (150 Gm.). 

Aqua rosa ... Jiiss (75 Gm.). 

Soda boratis . gr. xxxvj (2.4 Gm.). 

Sulphuris pra- 

dpitati . 5vij (28 Gm.). 

M. et ft. cremor. 

Deep brushing with a long bristle 
brush for a few minutes night and 
morning is also advised, and elec¬ 
tricity and vibratory massage have 
their advocates. 

Pilocarpine is the only drug that 
appears to exert a specific action. 

IJ Pilocarpina 
hydrochlo- 

ridi .gr. XX (1.3 Gm.). 

Aqua colonien- 
sis .3iv (120 Gm.). 

Aqua rosa, 

Alcoholis ab- 

soluti -aa 5ij (60 Gm.). 

M. Sig.: To be well rubbed in 
night and morning. G. T. Jackson 
and McMurtry (Med. Fortnightly, 
May 25, 1914). 

Report of 3 years’ experience with 
an ultraviolet ray quartz lamp utiliz¬ 
ing 3M> amperes on a 220 direct cur¬ 
rent. Practically all forms of alope¬ 
cia respond to it, even alopecia senilis 
showing favorable results and alo¬ 
pecia areata and trichophytina always 
responding rapidly. The distance 
from lamp to skin is 10 inches, and 
the initial time of exposure 15 min¬ 
utes in blondes and 20 to 25 minutes 
in brunettes and gray persons. The 
younger the subject, the less the ex¬ 
posure. A given area can be treated 
but once a week, though with due 
local protection other parts can be 
treated on the same or following 
days. The eyes are protected by 
colored spectacles, and other exposed 
parts by zinc oxide plaster or 2 layers 
of towels. Hair that might obstruct 
the rays must be held away from the 
area to be treated, a bathing cap with 
appropriate windows being conven- 







ALOPECIA AREATA (SCIIAMBERG). 


551 


lent. In recent cases a single treat¬ 
ment at times yields a cosmetic cure; 
in other patients a dozen exposures 
are required for satisfactory changes. 
Dieffenbach (Amer. Jour. Electro- 
therap. and Radiol., Sept., 1917). 

In 25 cases observed by the writer, 
alopecia usually occurred 2 or 3 
months after the onset of influenza, 
though occasionally during convales¬ 
cence. It was generally of the diffuse 
type, although in 1 hospital case and 
1 private case the lesions were patchy. 
In 21 cases the patients were females, 
but all were under 36 years of age. 
The aim should be to promote a 
healthy circulation of the scalp by 
massage with the head lowered; by 
avoidance of obstruction to the main 
vessels of supply to the scalp by pad¬ 
ding the hat band, and by stimulating 
lotions. Ayres (Boston Med. and 
Surg. Jour., Apr. 24, 1919). 

Jay F. Schamberg, 

Philadelphia. 

ALOPECIA AREATA.-Alope¬ 
cia circumscripta; area celsi. 

DEFINITION.—Alopecia areata 
is a disease of the hairy system char¬ 
acterized by the more or less sudden 
occurrence of round or oval circum¬ 
scribed bald patches, in rare cases 
coalescing and producing total bald¬ 
ness. 

SYMPTOMS. —The disease is 
usually limited to the scalp. The 
patches are circumscribed and round, 
and vary in size from a coin to the 
palm of the hand. The skin is 
smooth, soft, of a dead-white color, 
and totally devoid of hair. Occasion¬ 
ally the patches are pinkish as a 
result of slight hyperemia. The fol¬ 
licular openings are contracted and 
less prominent than in the healthy 
scalp. 

To the feel the skin is thin, soft, 
and pliable. In the beginning, the 
patches are level or slightly ele¬ 


vated, while later they are sometimes 
slightly depressed. 

The course of the disease is ex¬ 
tremely variable. In some cases the 
bald patches develop suddenly in the 
course of a few hours. In other 
cases, the hair loss is gradual, extend¬ 
ing over a period of a few days or 
weeks. The areas then spread by 
peripheral extension until they reach 



Alopecia totalis following an ordinary alopecia 
areata. (Schamberg.) 


a certain size, when they remain sta¬ 
tionary. 

In some cases the entire scalp 
becomes denuded of hair, giving to 
the patient a most grotesque appear¬ 
ance. In extensive cases it is by no 
means rare for the eyebrows and eye¬ 
lashes to be lost. In men the bearded 
region of the face may be involved, 
either alone or in conjunction with 
the scalp. 

The duration of the disease varies 






552 


ALOrECIA AREATA (SCHAMBERG). 


greatly. Recovery seldom occurs in 
less than a few months, while many 
cases last several years. The disease 
may occur at any period of life. In 
young individuals the hair usually 
returns sooner or later. In adults, 
the baldness may persist and prove 
refractory to all treatment. 

When regrowth occurs, the patch 
is first covered by fine, downy, whitish 



Alopecia areata. Sckamberg. 

hairs which are either shed or later 
converted into coarse and pigmented 
hairs. Not infrequently the hair 
grows in and the patient thinks he is 
on the road to recovery, only to have 
his hopes shattered by the hair falling 
out again. As a rule, there are no sub-| 
jective symptoms to be observed in 
such cases. 

Alopecia areata occurs with similar 
frequency in the two sexes. It is 
more common in youth and early 
adult life than in other age periods. 


Crocker states that, of 506 hospital 
cases, 214 were under 15 years of age, 
and 214 occurred in persons between 
the age of 15 and 35. 

ETIOLOGY. —There are two dis¬ 
tinct theories of the causation of 
alopecia areata. One school insists 
that the disease is parasitic, and cites 
occurrences of epidemics in institu¬ 
tions as proof of this view. Epi¬ 
demics have been observed chiefly in 
France and Germany: Bowen and 
Putnam have also published the details 
of an outbreak in an institution in this 
country. 

The cause of alopecia areata is not 
an infection, but some neurotrophic 
influence. Division of the second cra¬ 
nial nerve experimentally causes it; 
besides, thallium acetate applications 
cause neurotrophic affections of the 
entire body. And with atrophy of 
the fibers of the sympathetic nerves 
in certain regions alopecia results, 
especially when the trigeminus is 
affected. From his observations the 
writer believes alopecia areata al¬ 
ways to be neurotrophic in character. 

E. Richter (Berl. klin. Woch,, Dec. 
29, 1902). 

Alopecia areata is trophoneurotic 
in origin, as first urged by Jacquet, 
who noted some close relation be¬ 
tween alopecia and dental neuralgia. 
His investigations show that neural¬ 
gia occurs before, with, or after the 
alopecia, in almost all cases. This 
dental theory of the origin of alo¬ 
pecia is confirmed by a case-history 
which the writer quotes, a child in 
whom the condition disappeared after 
the affected gum had been cauterized. 

F. Tremolieres (Presse med., June 
14, 1902). 

Recalling Jacquet’s theory that 
baldness is of nervous origin, and is 
connected with skin diseases, dental 
troubles, and crises of gastrointes¬ 
tinal and other origin, the writer re¬ 
fers to a case in which the cure of a 
fistula in ano, complicated with en¬ 
tire loss of hair, was succeeded by 






ALOPECIA AREATA (SCHAMBERG). 


complete restoration of eyelids, eye¬ 
brows, and hair of the scalp. Eyraud 
(Presse med.. Mar. 30, 1904). 

There exists a more or less inti¬ 
mate and obvious relationship be¬ 
tween genital disturbances and this 
disorder. In the female sex there is 
a form of alopecia that follows the 
menopause and even a prolonged sup¬ 
pression of the menses. Such alo¬ 
pecia may be either mild or severe. 
This disease may also follow oophor¬ 
ectomy, and here again the prognosis 
is variable. In less frequent instances 
alopecia appears, usually in a mild 
form, in the course of several con¬ 
secutive pregnancies. R. Sabouraud 
(Annales de dermat. et de syphil., 
Feb., 1913). 

Instance in an Italian boy, 5 years 
old, of ringworm of the scalp and 
alopecia areata appearing simultane¬ 
ously in th-e same location. He 
deemed it of some interest on ac¬ 
count of its possible bearing on the 
cause of some of the epidemics of alo¬ 
pecia areata occasionally reported. 
J. E. Lane (Boston Med. and Surg. 
Jour., Jan. 11, 1917). 

Illustrations of the teeth of piersons 
with alopecia areata. Some initial 
teratologic disturbance is responsible 
for the tendency for the hair to fall 
out, and for the defective teeth and 
defective growth of teeth and nails. 
Inherited syphilis is sometimes but 
not always responsible. Sabouraud 
(Presse Med., Aug. 23, 1917). 

On the other hand, there is irrefu¬ 
table clinical evidence of the neuro¬ 
pathic origin of cases of alopecia 
areata. Nervous shock, such as 
fright, prolonged anxiety, etc., and 
traumatism to the scalp have been 
directly followed by areate loss of hair. 

[I recently saw a boy admitted to the 
Polyclinic Hospital for the fracture of the 
skull who developed alopecia areata be¬ 
fore leaving the institution. Max Joseph 
has produced the disease in cats by ex¬ 
cision of the second cervical ganglion. 
J. F. S.] 

It would, therefore, appear that 


553 

there are two varieties of alopecia 
areata, the one parasitic and the other 
trophoneurotic. In the epidemic ob¬ 
served by Bowen and Putnam, the 
patches were not identical with those 
commonly observed, but were smaller 
and more irregular in shape. Some 
of the English dermatologists are of 
the opinion that alopecia areata is 
prone to occur in those who have at 
some previous period suffered from 
ringworm of the scalp. 

Stimulating and antiparasitic reme¬ 
dies give the best chance of success 
in this affection, and in early cases 
there is a fair prospect of arresting 
the disease. The hair obtains its 
nutrition from the papilla, and the 
difficulty of reaching the deeper 
parts of the hair-follicle by external 
application must be borne in mind. 
The best remedies are probably those 
which keep the skin of the patch in a 
state of slight permanent irrigation, 
and this object may be o-btained by 
the daily application of moderately 
strong irritants, such as tincture of 
iodine, lactic acid, acetic acid, chry- 
sarobin, sulphur and mercurial oint¬ 
ments. The author has found (1) 
the B. P. unguentum hydrargyri 
iodidi rubri (diluted from 4 to 2 per 
cent.); (2) the unguentum hydrargyri 
oxidi rubri, v/ith acetum cantharidis, 
3j to Bj (4 to 30 Gm.), and (3) equal 
parts of sodium chloride and petro¬ 
latum—used for the treatment of 
ringworm—serviceable for their anti¬ 
septic and stimulating properties. 
S. E. Dove (Clin. Jour., Jan. 21, 1914). 

The great French dermatologist, 
Sabouraud, regards his microbacillus 
as the probable cause of alopecia 
areata, though the influence of syph¬ 
ilis is not overlooked by him. 

In a review of current theories— 
the parasitic, the neurotrophic, and 
the reflex irritation theory of Jacquet 
—the writer dismisses them all. In 
some families it is hereditary. It oc¬ 
curs not infrequently in connection 


554 


ALOPECIA AREATA (SCHAMBERG). 


with vitiligo and exophthalmic goiter. 
It is common in women at or about 
the menopause. Apart from these 
groups a large number of cases, at 
least in childhood and adolescence, 
are due to syphilis inherited in a lar¬ 
val form, a view fortified by excellent 
results obtained with mercurial treat¬ 
ment. R. Sabouraud (Ann. de Derm, 
et de Syph., Ser. 6, i, 177, 1920). 

PATHOLOGY. — Both Giovanni 
and Robinson found evidences of in¬ 
flammatory disturbances, chiefly in 
subpapillary layer. Perivascular cell 
infiltration was observed in both 
early and late lesions. Subsequently 
atrophic changes take place with 
destruction of the hair papillae. 

The characteristic hair of alopecia 
areata has the shape of an exclamation 
point. The upper part is pigmented 
and normal, while the lower portion 
is atrophied and without pigment. 
Sabouraud describes an ampullar swell¬ 
ing {the peladic utricle) filled with 
the microbacillus in the upper third 
of the hair follicle. 

Alopecia Areata. 

1. Rapid onset. 

2. Patches are :— 

(a) Totally devoid of hair. 

(b) Pale or whitish in color. 

(c) Smooth or soft. 

(d) Follicles contracted. 

3. Absence of fungus. 

4. Common in adolescence and adult life. 

The baldness of early syphilis may 
bear some resemblance to alopecia 
areata. Apart from the presence of 
other evidences of the disease, the 
patches are moth-eaten in appearance 
and not sharply circumscribed. The 
surrounding hair and scalp are luster¬ 
less and dirty, whereas in alopecia are¬ 
ata they are perfectly normal. 

PROGNOSIS. —In children recov¬ 
ery usually takes place. In young 


adults the prognosis is usually favor¬ 
able, while in advanced adults it is un¬ 
favorable. The longer the disease has 
persisted, the more unfavorable is the 
prognosis. The duration of the disease 
is uncertain and relapses are not un¬ 
common. 

TREATMENT. —The internal treat¬ 
ment consists of the use of such tonics 
as iron, strychnine, quinine, codliver 
oil, phosphorus, and arsenic. Duhring 
considers arsenic to be “especially ser¬ 
viceable.'’ 

The local treatment has for its pur¬ 
pose the stimulation and rubefaction of 
the scalp with the object of increasing 
the blood-supply to the follicles. Many 
cases terminate in spontaneous recov¬ 
ery, and conservative judgment is de¬ 
sirable in interpreting the value of 
remedies employed. Among the many 
medicaments which have been advised 
are alcohol, cantharides, capsicum, the 
essential oils, turpentine, carbolic 
acid, trikresol, ammonia, sulphur, 

Ringworm. 

1. Slow, insidious onset. 

2. Patches are :— 

(a) Covered with broken-off stumps. 

(b) More or less reddened. 

(c) Rough and scaly. 

(d) Follicles prominent; “goose-flesh” 

appearance. 

3. Trichophyton fungus present. 

4. Occurs almost exclusively in childhood. 

iodine, mercury, chrysarobin, beta- 
naphthol, etc. 

The following lotion will be found 
of value':— 

B Tinct. cantharides, 

Tinct. capsid, oi tdich fSiss (6.00 c.c.). 

01. ricim . fSij (8.00 c.c.). 

Aquce cologniensis . fSj (30.00 c.c.). 

Sig.: Brush in vigorously each day. 

Instead of lotions, ointments such as 
the following may be employed:— 



ALOPECIA AREATA (SCHAMBERG). 


555 


B Betanaphtholis .5j (4.00 Gm.). 

Vaselini . 5j (31.00Gm.). 

01. bergamot . (2.46c.c.). 

Sig.: Rub in twice a day. 

An efficient treatment consists in 
the swabbing of the bald areas once 
or twice a* week with 
Phcnolis, 

AlcohoUs, of each. f5ss (15.00 c.c.). 

Or, 50 per cent, trikresol may be 
employed. 

Within recent years I have em¬ 
ployed a chrysarobin ointment which 
has given me more uniformly good 
results than any other topical appli¬ 
cation :— 

Chrysaro- 

bini . gr. x-xxv (0.65-1.62 Gm.). 

Lanolini _ 5j (4.00 Gm.). 

A dip is bcnzo- 

inati ...... 5vij (27.21 Gm.). 

M. Rub in in small quantity. Protect 
the eyes from contact with ointment. 

Case of a young girl in which there 
was a circular patch three inches in 
diameter on the scalp at the side of 
the occiput, hairless, smooth, and 
shining. The treatment consisted in 
painting it with a 30 per cent, solu¬ 
tion of formaldehyde. This was done 
every day for the first week or two, 
until signs of inflammatory reaction 
appeared. The treatment was then 
suspended, and a sedative ointment 
applied. When the inflammation sub¬ 
sided the formaldehyde was again 
continued, stopping the application 
as soon as inflammatory trouble ap¬ 
peared. This routine of treatment 
was persevered in for about six or 
nine months. About this time a 
growth of hair made its appearance, 
continued to grow, and in every way 
corresponded with the surrounding 
hair. One year after cessation of 
treatment the growth of hair was 
continuing in a perfectly normal way. 
J. J. Mclnerny (Brit. Med. Jour., 
Jan. 25, 1908). 

The writer deems it a great mis¬ 
take to treat the patch of alopecia 


alone; the aim should be especially 
to prevent the development of new 
patches. Another error is to wait to 
see whether the alopecia will subside; 
it is better to treat it from the first 
as if it were going to be a grave 
form. He advises to brush the en¬ 
tire scalp with a hard toothbrush 
dipped in a tonic and irritant mix¬ 
ture. His formula for this is: cologne 
water, 300 c.c. (10 ounces); glacial 
acetic acid, 10 Gm. {2V2 drams), and 
commercial solution of formaldehyde, 
1 Gm. (15 grains). A lotion of 30 
Gm. (1 ounce) of Hoffmann’s fluid 
with 1 Gm. (15 grains) of glacial 
acetic acid is applied to the patch 
itself and its vicinity. In case the 
course of the alopecia seems threat¬ 
ening rapid extension, the small hairs 
broken off 3 or 4 mm. above the skin, 
he resorts to a cade oil salve. Men 
rub it in every evening and wash it 
out with soap in the morning; women 
three times a week with a weekly 
soap shampoo. The general health 
improves under mercurial treatment, 
as well as" the alopecia; the writer’s 
success in this line has been so striking 
that he advocates mercurial treatment 
for young people with poor health or 
vague disturbances even if the idea 
of syphilis seems preposterous. When 
the alopecia develops at the meno¬ 
pause, ovarian treatment may aid, but 
spontaneous recurrence of hair is of¬ 
ten observed. R. Sabouraud (Presse 
med., Dec. 4, 1920). 

The faradic current applied with a 
wire brush electrode is often useful, as 
is likewise the use of high-frequency 
currents. In obstinate cases blister¬ 
ing of the afifected areas may be re¬ 
sorted to. 

PHOTOTHERAPY.— Many writ¬ 
ers, including Finsen, Hyde, Mont¬ 
gomery, Kromeyer, and others, have 
testified to the value of actinic light 
rays in this disease. It is admitted 
that many cases in which light is used 
might have recovered spontaneously. 
Kromeyer’s results, however, in cases 








556 


ALUM (SAJOUS). 


of extensive and even total alopecia 
of years’ standing indicate that light 
therapy is one of the most useful 
measures in the treatment of this 
disease. 

The iron arc or carbon arc may 
be employed. The ordinary London 
Hospital type of lamp suffices for this 
purpose and permits of the exposure 
of a surface area of the size of a silver 
dollar. 

Reaction varying in degree from an 
erythema to the formation of a blister 
results at the end of some hours. 
The same area can be again treated 
after the expiration of two or three 
weeks. 

Severe case of alopecia areata, re¬ 
bellious alike to applications of mer¬ 
cury bichloride, pilocarpine, croton 
oil, etc,, as well as to the use of a 
constricting band and to internal 
medication, in which exposures of the 
affected areas to the ultraviolet rays, 
by means of Kromeyer’s lamp, gave 
good results. These rays induce pro¬ 
nounced and prolonged cutaneous 
hyperemia. They are both more ac¬ 
tive and safer than the X-rays. R. 
Horand (Lyon med., Aug. 18, 1912). 

The ultraviolet rays have given ex¬ 
cellent results in the writer’s hands in 
cases of alopecia areata and other 
dermatoses. A. Fischkin (Ills. Med. 
Jour., May, 1916). 

The quartz lamps (Kromayer and 
Alpine) are cleanly and convenient 
agents for the treatment of alopecia 
areata. The results in 50 cases, 
.though not brilliant, were at least 
satisfactory. More than half of the 
patients were followed to complete 
recovery, while in 78 per cent, of the 
cases the new hair had at least begun 
to grow. Fox (Med. Rec., Nov. 27, 
1920). 

Jay F. Schamberg, 

Philadelphia. 

ALSOL. See Aluminum : Alu¬ 
minum Acetotartrate. 


ALUM (Aliimen ).—The alum used 
in medicine is, chemically, the double 
sulphate of aluminum and potassium 
[A1K(S04)2+I2H2O]. It occurs 
in large, octahedral, translucent crys¬ 
tals, or as a colorless powder, odor¬ 
less, but with a. sweetish, strongly as¬ 
tringent taste. When left in an open 
bottle, the salt becomes whitish on the 
surface, owing to the absorption of 
ammonia from the air. Dried, “burnt,” 
or exsiccated alum (Alnmen Exsicca- 
tum), i.e., alum from which the water 
of crystallization has been driven out 
by heating, occurs as a white, granu¬ 
lar, strongly hygroscopic powder. 

DOSE. —The dose of alum for in¬ 
ternal use (rarely employed) is 5 to 
30 grains (0.03 to 2.0 Gm.) ; the aver¬ 
age dose is 71/2 grains (0.5 Gm.). To 
secure an emetic effect, 1 to 2 drams 
(4 to 8 Gm.) must be given. 

MODES OF ADMINISTRA¬ 
TION. —Alum is soluble in 9 parts of 
cold water (the saturated solution thus 
containing, roughly, 10 per cent.), and 
in 0.3 parts of boiling water. It is 
completely insoluble in alcohol, but dis¬ 
solves readily in warm glycerin. Dried 
alum, possessing greater concentration 
than the crystalline form, requires more 
water for dissolution—17 parts of cold 
and 1.4 parts of boiling water. When 
exhibited for other purposes than as 
an emetic, alum is best given in a fla¬ 
vored syrup, e.g., syrup of orange peel. 
When it is used to secure emesis, a 
small amount of simple syrup may be 
employed as vehicle. The subsequent 
ingestion of warm water augments its 
emetic effect. For astringent gargles, 
sprays, anhydrotic lotions, and rectal 
or vaginal injections, solutions contain¬ 
ing 21/2 to 20 grains (0.15 to 1.2 Gm.) 
of alum to the ounce (30 c.c.) of water 
should be prescribed. When an astrin 


ALUM (SAJOUS). 


557 


gent eye-wash is desired, 2 or 3 grains 
(0.12 to 0.20 Gm.) of alum to the 
ounce of water may be used. The “alum 
curd,” made by adding to a pint (473 
c.c.) of milk 2 drams (8 Gm.) of alum, 
boiling the mixture, and straining off 
the curd, is also a useful preparation 
for this purpose. Dried alum, being 
anhydrous, is especially adapted for 
use as a dusting powder, for insuffla¬ 
tion, and in ointments. It is applied to 
superficial growths as an escharotic. A 
glycerite of alum is official in the Brit¬ 
ish Pharmacopoeia. 

INCOMPATIBLES.—The salts of 
aluminum, including alum, are incom¬ 
patible with the alkalies and carbonates 
of the alkali metals; with the tartrates; 
with tannic acid, and with salts of iron, 
mercury, and lead. 

CONTRAINDICATIONS.—In in¬ 
dividuals subject to bronchial irritation, 
the long-continued use of alum is inad¬ 
visable, in view of the exciting effect it 
exerts on these structures. 

PHYSIOLOGICAL ACTION.— 
When applied externally alum causes 
hardening of the skin, or, if used in 
concentrated solution, exerts a slight 
caustic effect. Whenever it is brought 
in contact with albumin, as occurs when 
it is applied to a denuded area, the al¬ 
bumin is coagulated. The precipitate is 
soluble, however, if an excess of albu¬ 
min be present. 

The familiar astringent and antisep¬ 
tic effects of alum and other aluminum 
salts depend upon this coagulating 
property. Their power of penetrating 
into tissue-cells is, however, very 
limited according to Siem. Yet it is 
very effective when hemorrhage for in¬ 
stance is of capillary origin. 

Small doses of alum taken orally at 
first stimulate the flow of saliva, then 
reduce it through their astringent ef¬ 


fect. The buccal mucosa becomes 
whitish and shriveled, owing to coagu¬ 
lation of the albuminous constituents, 
and the enamel of the teeth is likely to 
crack in places. On reaching the stom¬ 
ach, the drug causes a decrease in the 
amount of gastric juice secreted, and 
coagulates the pepsin. A similar effect 
being exerted in the intestinal canal, 
constipation results. In larger doses, 
the emetic effect of alum becomes man¬ 
ifest, and a purgative effect may also be 
noted, irritation succeeding the prelim¬ 
inary astringent effect. 

^ UNTOWARD EFFECTS AND 
POISONING.—The injurious effect 
of alum on the teeth may be avoided 
(1) if care be taken to cleanse them 
well at once after employing an alum 
gargle or mouth-wash; (2) by limiting 
the use of alum to applications of a 
strong solution or of the solid salt in 
all cases in which local astringent ef¬ 
fects will suffice. The unfavorable ac¬ 
tion of alum when long employed by 
persons subject to bronchial irritation 
has already been referred to. 

The influence of alum in baking 
powders was studied by a Referee 
Board of Consulting Scientific Ex¬ 
perts composed of R. H. Chittenden, 
A. E. Taylor, and J. H. Long, ap¬ 
pointed by the U. S. Department of 
Agriculture. The general conclusion 
reached was that alum baking pow¬ 
ders are no more harmful than any 
other baking powders, but that it is 
wise to be moderate in the use of 
foods that are leavened with baking 
powder. (Bulletin No. 103, Apr. 29, 
1914). 

Large amounts of alum taken inter¬ 
nally cause nausea, vomiting, pain in 
the abdomen, and diarrhea, owing to 
the inflammation of the gastrointestinal 
mucosae produced through the cellular 
albumins. 


558 


ALUM (SAJOUS). 


Case in which, through gargling with 
a concentrated alum solution, a portion 
of the fluid was accidentally swallowed. 
This was followed by severe abdominal 
pains, vomiting of mucus and blood 
(39 times), and voiding of blood¬ 
stained urine. Recovery only after the 
lapse of thirteen days. Kramolin 
(Therap. Monatsh., 325, 1902). 

Alum baking powders and pastry to 
which alum has been added in order to 
whiten the product are possible sources 
of gastrointestinal irritation, though the 
amount of aluminum liberated, at least 
in the case of bread baked with alum 
powders, is often so slight as to be of 
doubtful importance. 

THERAPEUTIC USES. —As an 
Astringent.—This is the chief use of 
alum. Combined with it is an antisep¬ 
tic effect, which is also of value. 

In all catarrhal and relaxed states 
of the mucous membranes, as well as 
in certain skin affections, alum is bene¬ 
ficial when locally applied. Aqueous 
solutions of from 5 to 20 grains to the 
ounce (1 to 4 per cent.) strength are 
chiefly employed; stronger solutions in¬ 
duce undesirable secondary irritation. 

In catarrhal throat affections fluid 
preparations containing alum (1 to 5 
per 'Cent.) form a useful gargle or 
spray. Since alum is injurious to the 
teeth, the mouth should be washed 
out, preferably with s-ome alkaline so¬ 
lution, after using this drug. A 
glycerite of alum (10 to 20 per cent, 
solution of alum in glycerin, the prep¬ 
aration of which is greatly facilitated 
by heating) is very efficacious when 
applied locally in subacute pharyn¬ 
gitis and laryngitis, especially where 
a tendency to edema of the tissues in¬ 
volved is present. For the relief of 
hoarseness or of tickling sensations 
in the throat, a mixture of equal parts 
of powdered alum and sugar, placed 


on the tongue and allowed slowly 
to dissolve, is productive of benefit 
(Bunnell). 

In acute coryza alum has been 
incorporated in snuff, to which it 
imparts astringency. The following 
preparation is suitable for use in the 
early stages of coryza:— 

Alum . 3 grs. (0.2 Gm.). 

Morphine sulphate . 2 grs. (0.13 Gm.). 

Cocaine hydrochlo- 
Ade . 1 gr. (0.065 Gm.). 

Camphor, 

Bismuth -of each 2 drs. (7.77 Gm.). 

M. bene. Sig.: To be used as snuff every 
two hours; a small quantity in each nostril. 

In follicular tonsillitis and diph¬ 
theria alum in pencil form may be 
applied to the involved surfaces with 
benefit. 

In conjunctivitis alum may also be 
used. A 0.5 per cent, solution may be 
used as a lotion, or the alum curd, 
made by the addition of powdered 
alum to milk or white of egg until 
a curdy mass is formed, may be ap¬ 
plied to the eye every two hours. 
Similar applications prove effective 
in ecchymosis of the eyelid (black 
eye). In gonorrheal ophthalmia alum 
has also been used in a solution con¬ 
taining 6 grains of the salt in 1 ounce 
of water, applied four times daily. In 
granular conjunctivitis a crystal of 
alum may be drawn over the involved 
mucous surface after turning the lid 
(Bunnell). 

In salivation or ptyalism of mer¬ 
curial origin a 4 per cent, solution of 
alum may be employed for its astrin¬ 
gent action. 

In the treatment of night-sweats, or 
in sweating .of the hands and feet 
(hyperidrosis), washing the skin sur¬ 
faces with a 0.5 per cent, solution of 
alum will markedly improve the con¬ 
dition. 




ALUM (SAJOUS). 


559 


In chilblains a 4 per cent, solution 
of alum has been applied with benefit. 

In gonorrhea and leucorrhea alum 
has been used as an astringent injec¬ 
tion or douche in % to 2 per cent, 
strength. 

In pruritus vulvae a 4 per cent, so¬ 
lution of the salt will not infrequently 
relieve the itching. 

In ingrowing toenail with granula¬ 
tions absorbent cotton soaked in a 6 
per cent, solution of alum may be in¬ 
troduced under the edge of the nail. 

In chronic dysentery a 1 per cent, 
solution of alum is sometimes em¬ 
ployed as a rectal injection. 

As a styptic alum is likewise an 
effective agent. 

In epistaxis it will often act 
promptly. Pledgets of cotton should 
be dipped in a saturated solution of 
alum and packed in the bleeding cav¬ 
ity ; they may be left in until all 
danger of recurrence has passed— 
generally about twelve hours. In 
minor degrees of hemorrhage the 
alum solution may be sprayed in, or 
powdered alum may be used as snuff 
or introduced by means of an insuf¬ 
flator. 

Similarly, in hemorrhage succeed¬ 
ing upon the extraction of teeth, the 
placing in the cavity of cotton dipped 
in a saturated solution, or the intro¬ 
duction of powdered alum, will often 
be effective in arresting the bleeding. 

In hemoptysis a fine spray of 5 per 
cent, alum solution is claimed to 
have been productive of benefit. 

In the intestinal hemorrhage of ty¬ 
phoid fever alum has been recom¬ 
mended by many clinicians, Whitla 
in particular. It is believed to do 
good in this condition through its 
antiseptic properties, as well as 
through its astringency. 


In uterine hemorrhage of all kinds 
alum is a useful styptic. It may be 
employed as an injection in the 
strength of 1 dram to the pint, or, 
as R. Beverly Cole recommended, an 
egg-shaped piece of alum may be 
inserted into the uterine cavity. Not 
only is the styptic effect produced, 
but the tissues of the uterus are stim¬ 
ulated and the organ is caused firmly 
to contract. 

As a Caustic.—Dried (“burnt”) 
alum, which exerts an escharotic ef¬ 
fect, owing to the fact that in addi¬ 
tion to the inherent properties of 
alum it withdraws water from the 
tissues, may be applied to exuberant 
granulations, condylomata, chronic 
conjunctival inflammations, etc. 

Burnt alum may also be used as a 
dressing for sluggish ulcerations and 
as an application to swollen gums 
and in ulcerative stomatitis (Bun¬ 
nell). 

As an Emetic.—In doses of 1 or 2 
drams alum has been used as an 
emetic, especially in the treatment of 
croup in children. A teaspoonful of 
the salt may be dissolved in 6 table¬ 
spoonfuls of a mixture of syrup and 
water, equal parts, and administered 
every fifteen minutes. 

This sometimes serves quickly to ar¬ 
rest an impending attack of croup, the 
astringent effect of the salt upon the 
mucosa of the throat contributing in the 
benefit by counteracting the local hyper¬ 
emia. 

As a Stimulant to Peristalsis.—In 
doses of % dram every four hours 
alum has been found to induce purga¬ 
tion. The large amount of watery fluid 
thrown out from the mucosae in the 
presence of alum apparently obviates 
its irritating influence on these mem¬ 
branes. In tympanites due to peri- 


560 


ALUMINUM (SAJOUS). 


toneal inflammation succeeding upon 
abdominal operations in cases suffer¬ 
ing from infective states of the ab¬ 
dominal viscera, the high rectal in¬ 
jection of an ounce of alum in a quart 
of water has been found effectively 
to excite contractions of the paretic 
gut. 

Case in which Epsom salt, calomel, 
soap and water, castor oil, glycerin, 
turpentine, and oxgall were success¬ 
ively used without avail. A solution 
of an ounce of powdered alum in a 
quart of warm water was injected into 
the rectum, and in ter minutes flatus 
escaped from the rectum. In an hour 
the enema was repeated successfully. 
The patient was practically convales¬ 
cent on the following day. Since this 
case, the author has used the alum 
enema in hundreds of cases, and always 
with good results. Sometimes it is 
necessary to repeat the injection be¬ 
fore it will act, and this can be done 
with safety an indefinite number of 
times. 

There is sometimes some pain, not 
severe, attending its use. Injected 
like any other enema, probably in no 
instance does it go above the sigmoid 
flexure. The throwing off by the bowel 
of a tubular cast is of no importance, 
as it is composed simply of mucus 
whose albuminous elements have been 
coagulated by the alum. 

The alum seems to have as specific 
an action in inducing intestinal peri¬ 
stalsis as has castor oil when taken into 
the stomach. It does not produce a 
serous exudation from the intestinal 
walls, and for that reason the author 
prefers it to Epsom salt when the 
stomach will retain it. During nine 
years in which alum enema was used, 
percentage of mort..lity in abdominal 
work has been a little less than one- 
half of what it was during the pre¬ 
ceding seven years. Hardon (Amer. 
Jour, of Obstet., June, 1901). 

C. E. DE M. Sajous 

AND 

L. T. DE M. Sajous, 
Philadelphia. 


ALUMINUM {Aluminium). — A 
bluish-white, silvery metal, noted for 
its low specific gravity (2.7) and its 
unalterability on exposure to the air. 

The most important of the com¬ 
pounds of the metal aluminum em¬ 
ployed in medicine, viz., the double 
sulphate of aluminum and potassium, 
has already received separate consid¬ 
eration {v. Alum). Numerous other 
salts have been used, chiefly exter¬ 
nally, as astringents and antiseptics. 

Taken internally, the salts of alumi¬ 
num are, according to some observers, 
not all absorbed from the gastrointesti¬ 
nal tract, this accounting for the fact 
that no functional disturbances in the 
organism at large occur as a result of 
their ingestion. According to others, 
however, alum (and probably other 
salts) is absorbed, in extremely small 
amount, in the alimentary canal, and 
is eliminated with the bile and urine. 
When administered experimentally 
to animals by subcutaneous injection, 
soluble salts of aluminum cause no 
symptoms at all until several days or 
even weeks later (Siem), when the 
metal is no longer present in the cir¬ 
culation. In mammals the symptoms 
appear in from three to five days, and 
are in many ways similar to those of 
subacute arsenic poisoning. The ani- 
mial shows loss of appetite, obstinate 
constipation, emaciation, and languor. 
Next there appears vomiting. Vol¬ 
untary movements, executed only 
upon coercion, are attended with 
trembling and twitching. Sometimes 
there is general tremor or convulsive 
twitching, and sometimes extreme 
weakness or partial paralysis of the 
posterior limbs. There is complete 
loss of sensibility to pain, though 
'consciousness is retained. Finally, 
control of the tongue and the power 


ALUMINUM (SAJOUS). 


561 


of swallowing are completely lost, sa¬ 
liva dribbling from the mouth. The 
symptoms correspond precisely to 
those of human acute bulbar paraly¬ 
sis. Such phenomena never result 
from the oral use of aluminum salts, 
even where long continued (Soll- 
mann). Diarrhea and albuminuria 
appear before death. On post-mortem 
examination the gastrointestinal mu¬ 
cosae are found hyperemic and swol¬ 
len, and the kidneys and liver fre¬ 
quently show fatty degeneration, the 
former presenting, in addition, corti¬ 
cal hemorrhages. 

When aluminum vessels were first 
used for cooking some doubt existed 
as to their safety. Increasing experi¬ 
ence has shown that such objections 
do not exist. The writer observed 
that the largest amount of aluminum 
was detached when marmalade was 
made with oranges and lemons, but 
the amount recovered was so small 
that it would have been perfectly 
harmless even if the entire ounces 
of preserves had been eaten at one 
meal by a single individual. John 
Glaister (Editorial Therap. Gaz., 
Sept, 1913). 

When aluminum, in the form of 
aluminum lactate or sodium alumi¬ 
num lactate, is fed to rabbits, cats, 
or dogs for long periods of time, cer¬ 
tain distinct effects such as diarrhea, 
with, at autopsy, corrosion of the 
stomach, together with congestion, 
and a hemorrhagic condition of the 
intestinal mucosa result. Large doses 
caused numerous areas of intestinal 
hemorrhages and a few areas of 
ulceration, which were especially 
marked in the large intestine. Roth 
and Voegtlin (Jour. Pharm. and Ex- 
per. Therap., Feb., 1916). 

Following are some of the more 
important salts of aluminum em¬ 
ployed in medicine:— 

Aluminum Hydroxide (Alumini 

Hydroxidum), Al(OH) 3 , made by 

1 - 


precipitating a soluble salt of alumi¬ 
num with an alkali or alkaline car¬ 
bonate. It occurs as a light, amor¬ 
phous, colorless, tasteless powder, 
soluble in acids and alkalies. It is 
used as an astringent in inflamma¬ 
tory skin affections. 

Aluminum Sulphate (Alumini Sul¬ 
phas), AU( 804)3 + I 8 H 2 O, prepared 
from the hydroxide by dissolving it 
in dilute sulphuric acid. It occurs as 
a white, crystalline powder or in larger 
crystals or pencils, and, like alum, has 
a sweetish and astringent taste. It 
is freely soluble in water, and has 
been used for much the same pur¬ 
poses as alum itself, viz., as an astrin¬ 
gent, antiseptic, and caustic in the 
treatment of affections of the nose 
and throat, including enlarged tonsils 
and nasal polypi; of the uterus, includ¬ 
ing endometritis; as a lotion for foul 
ulcers, and in vaginal conditions as¬ 
sociated with offensive discharges. 
The strength of the solutions used is 
the same as with alum. 

The following aluminum com¬ 
pounds are non-official:— 

Aluminum Acetate (basic), AI 2 O,- 
4 C 2 H 3 O 2 + 4 H 2 O. Obtained in solid 
form from its solutions by rapid dry¬ 
ing on glass at a low temperature, 
this salt occurs as a colorless, crystal¬ 
line or amorphous powder which is 
insoluble in water. It is antiseptic 
and astringent, and has been used in¬ 
ternally in dysentery in doses of 5 to 
10 grains (0.3 to 0.6 Gm.). An 8 per 
cent, solution of aluminum acetate is 
known as “liquor Burowii,’^ which 
has been extensively used as an appli¬ 
cation in skin affections, and in sup¬ 
purating wounds. One to 3 per cent, 
solutions are useful as a mouth-wash, 
and are particularly effective in over¬ 
coming fetid breath. In a solution of 

-36 


562 


ALUMINUM (SAJOUS); 


1 to 150 strength, this salt of aluminum 
may be used as an astringent enema in 
affections calling for such a measure. 

Usefulness of aluminum acetate solu¬ 
tion emphasized. For certain surgical 
purposes this is one of the best anti¬ 
septic solutions, though it is unknown 
to most surgeons and practitioners. 
Burns may be treated with dressings 
wetted with a 1 per cent, solution of 
aluminum acetate. This solution, while 
antiseptic, is also non-toxic, non-irri¬ 
tant, and yet markedly astringent. It 
is not to be employed in surgical opera¬ 
tions, as it spoils steel instruments; but 
as an antiseptic for moist fomentation 
of wounds that are infected or prob¬ 
ably unclean, or as a medicament for 
a bath in which to place an infected 
hand or foot for continuous irriga¬ 
tion, it is to be strongly recom¬ 
mended. The common strength is 
that of 1 dram of the liquor aluminii 
acetatis of the German Pharmaco¬ 
poeia (a per cent, solution) to 1 
fluidounce of water. There is no 
danger of poisoning from it. By the 
employment of continuous irrigation 
by means of a bath of the 1 per cent, 
solution, pyogenically infected hands 
and feet, which but for the action of 
the solution would have called for 
amputation, have been saved. For 
dermatitis, whatever its cause; for 
suppurating open wounds, and for 
cutaneous erysipelas, much is to be 
said for the favorable results ob- 
, tained. One objection that should be 
mentioned is that after three weeks 
of continuous irrigation of a member 
such as the hand the surface tissues 
may assume a ligneous hardness. M. 
F. Waterhouse (Hospital, Aug. 27, 
1910). 

The writer observed 3 cases in 
which dressings with solution of 
aluminum acetate produced necrosis 
of the injured hand. The effect of the 
dressing was similar to the burns 
caused by phenic acid. Esau (Med. 
Klinik, July 14, 1912). 

Aluminum Acetotartrate (Alsol), 
prepared by mixing a 5 per cent, solu¬ 


tion of basic aluminum acetate with 
a 2 per cent, solution of tartaric acid 
and evaporating to dryness. It occurs 
in colorless crystals, or in whitish 
amorphous masses having a slightly 
acid, astringent taste. It dissolves 
slowly, but completely, in water, but 
is insoluble in alcohol and ether. 

This substance has an action sim¬ 
ilar to that of aluminum acetate, and 
is one of the best of the aluminum 
salts used in medicine. It has been 
employed largely, though not exclu¬ 
sively, in diseases of the respiratory 
passages. Thus in 0.05 to 2 per cent, 
solutions it has been used as a nasal 
douche. Mixed with 2 parts of pow¬ 
dered boric acid it may be used as a 
snuff. In tonsillitis a 1 per cent, so¬ 
lution of it makes a suitable gargle. 
Strong solutions {e.g., 50 per cent.) 
have been employed with advantage 
in the treatment of chilblains and 
skin diseases of various kinds—also 
in wounds as disinfectants. Eye af¬ 
fections, such as ophthalmia neona¬ 
torum, chronic types of conjunctivi¬ 
tis, etc., have also been treated with 
this salt. 

Solution of aluminum acetate is 
more efficacious than the commoner 
applications, iodine, ichthyol, lead and 
opium, etc., in the treatment of local 
congestions such as boils, carbimcles, 
and especially in facial erysipelas. 
He has used it also with marked suc¬ 
cess in severe cellulitis and inflamma¬ 
tory rheumatism and declares it the 
best remedy for ivy poisoning. Sev¬ 
eral thicknesses of gauze are soaked 
with the solution and applied to the 
part, covered with rubber tissue or 
oiled silk, and a bandage applied. It 
need be renewed only once or twice 
in 24 hours. Liquor alumini acetatis 
of the National Dispensatory is the 
best solution, and is made up as fol¬ 
lows: Aluminum sulphate (N. S. P.), 
acetic acid (N, S, P.), of each, 300 


ALUMINUM (SAJOUS). 


563 


Gm. (10 ounces); calcium carbonate 
(C. P.), 130 Gm. (4% ounces); dis¬ 
tilled water, 1000 c.c. (1 quart). 
Stansbury (Amer. Jour, of Surg., 
Feb., 1912). 

Aluminum Boroformate, prepared 
by saturating with freshly precipi¬ 
tated and well-washed aluminum a 
solution of 2 parts of formic acid and 
1 part of boric acid in 6 or 7 parts of 
water. It occurs in pearly scales, 
which are hygroscopic and dissolve 
completely, though slowly, in water. 
Its solution has a sweet, faintly 
astringent taste, and does not co¬ 
agulate solutions of albumin. Mar- 
tenson in 1894 recommended this salt 
strongly for use as a gargle in the 
throat affections in children, prefer¬ 
ring it to all other preparations of 
aluminum, partly owing to its relatively 
pleasant taste. 

Aluminum Borotannate (Cutal), a 
product of the reaction of tannic acid 
with borax and aluminum sulphate. 
It is a brownish insoluble powder, 
which combines with tartaric acid to 
form Aluminum Borotannotartrate 
(soluble Cutal). 

This salt, in common with the 
other aluminum compounds, is anti¬ 
septic and astringent. It has been 
used chiefly in skin affections and is 
recommended particularly in weep¬ 
ing eczema and pruriginous affec¬ 
tions. The following formula may be 
employed:— 

B Aluminum boro¬ 


tannate . 1 dr. (4 Gm.). 

Olive oil . drs. (10 Gm.). 


Lanolin..to make 10 drs. (40 Gm.). 

When the flow of secretions has 
been arrested, the drug may be used 
with advantage as a dusting powder 
and astringent in the following mix¬ 
ture :— 


Aluminum boro¬ 
tannate, 

Zinc oxide, 

Powdered talc, of 

each . lYz drs. (10 Gm.). 

In hemorrhoids Koppel has recom¬ 
mended the use of an ointment con¬ 
taining 10 per cent, of cutal, and in 
fissures of the hands of one formu¬ 
lated thus:— 

B Cutal . 54 dr. (3 Gm.). 

Oil of sweet alm¬ 
onds. 

Lanolin ..of each 354 drs. (IS Gm.), 
Orange-flower 

water .2j4 fl. drs. (10 Gm.). 

Aluminum borotannotartrate, or 
soluble cutal, has been used in the 
treatment of second-degree burns, as 
a 10 per cent, solution in glycerin in 
follicular throat affections, in catar¬ 
rhal metritis, in hemorrhoids, and in 
gonorrhea. 

Aluminum Borotartrate (Boral), a 
combination of aluminum, boric acid, 
and tartaric acid. It occurs as white 
crystals having a sweetish, astringent 
taste, and is freely soluble in water. 
It is useful in inflammatory diseases 
of the nose and nasopharynx, in ery¬ 
sipelas, and, in solution with tartaric 
acid, has given good results in gonor¬ 
rhea. It may be employed either 
alone in watery solution or in glycer- 
inated mixtures. 

Aluminum Carbonate, Al 2 (C 03 ) 2 , 
occurring in chalky-white, easily pow¬ 
dered, tasteless masses. According 
to Gawalewski, it constitutes an ex¬ 
tremely mild styptic and astringent, 
and is hence better adapted than are 
burnt alum and other aluminum prep¬ 
arations in the treatment of various 
ocular affections, croup, diarrhea, 
hemoptysis, skin eruptions^ and hy- 
peridrosis. 







564 


ALUMNOL. 


Aluminum Chloride, AI 2 CIG + 12- 
II 2 O, a yellowish granular, crystal¬ 
line, hygroscopic powder, soluble in 
water, alcohol, and ether. It has been 
used internally in tabes in doses of 
1% to 4 grains (0.1 to 0.25 Gm.), and 
externally as a disinfectant. 

Aluminum Phenolsulphonate (Sul- 
phocarbolate), A 12 (CgH 4 HS 04 )g, a 
reddish powder with weak phenol-like 
odor and a strongly astringent taste, 
soluble in water, alcohol, and glycerin. 
It has been recommended as a sub¬ 
stitute for iodoform in the treatment 
of superficial, circumscribed, suppu¬ 
rating lesions, and of cystitis. 

Aluminum Salicylate, A1 (CgH4- 
0 HC 00 ) 3 , a reddish powder, insol¬ 
uble in water and alcohol, soluble in 
alkalies. Used as an antiseptic pow¬ 
der for insufflation in catarrhal states 
of the nasal and pharyngeal mucous 
membranes, and in ozena. 

Aluminum Silicate, Al 2 Si 309 , a 
white substance, insoluble in water 
and acids. It has been recently rec¬ 
ommended in the treatment of gastric 
hyperacidity and hyperesthesia. 

Investigations of the action of sili¬ 
cate of aliimintim upon the gastric se¬ 
cretions and upon disease symptoms 
resulting from abnormalities of secre¬ 
tion. Under the name neutralon, this 
substance occurs as a fine, tasteless, 
odorless, and insoluble powder. 
Taken into the stomach,it reacts with 
the excess of hydrochloric acid to 
form silicic acid and aluminum chlo¬ 
ride. The latter acts as a protective 
and astringent to the gastric mucosa 
in a manner similar to silver nitrate 
and bismuth, and has no toxic effect. 
In all cases of hyperacidity or hyper¬ 
secretion, whether of neurotic origin 
or due to organic disease or injury, 
the remedy was found to be very 
effective in reducing the acidity, re¬ 
lieving pain, and aiding digestion. 
Results especially good in persistent 


cases of hypersecretion with motor 
insufficiency. Gastric hyperesthesia 
associated with anemia and chlorosis 
favorably influenced in several in¬ 
stances. Excessive acidity in cases 
of gastric ulcer was also reduced. 
The drug was given in doses of ^ to 
1 teaspoonful in 3 ounces of water, 
one-half to one hour before meals. 
No untoward symptoms. Rosenheim 
and Ehrmann (Deut. med. Woch., 
Jan. 20, 1910). 

C. E. deM. Sajous 

AND 

L. T. DE M. Sajous, 

Philadelphia. 

ALUMNOL, the aluminum sa;lt of 
betanaphthol-disulphonic acid [AkCCio- 
Hr,OH( 503 ) 2 ) 3 ], is made by adding a 
solution of barium naphthol-disulphonate 
to one of aluminum sulphate, filtering off 
the precipitate of barium sulphate, and 
evaporating to dryness. It contains about 
5 per cent, of aluminum, and occurs as a 
fine white or slightly reddish, hon-hygro- 
scopic powder with a sweetish, astringent 
taste. It is readily soluble in cold water 
and in glycerin, slightly so in alcohol, and 
is insoluble in ether. On exposure to the 
air it becomes darker in color, by virtue 
of its reducing properties. 

MODE OF EMPLOYMENT.—Alum- 
nol is employed chiefly in solution, though 
also frequently as a dusting powder. As 
a mild astringent and antiseptic it is used 
in solutions of 0.5 to 5 per cent, strength. 
For caustic effects, a 10 or 20 per cent, 
solution may be employed. Where the 
action of several antiseptics at once is 
desired, alumnol may be used in com¬ 
bination with agents such as corrosive 
sublimate, resorcin, etc.; it is incompatible, 
however, with silver nitrate or other re¬ 
ducible salts, as well as with alkalies. 

THERAPEUTIC USES.—The almost 
unirritating and non-toxic qualities of 
alumnol in weak solutions render it avail¬ 
able as an astringent and antiseptic for 
the treatment of chronic catarrhal proc¬ 
esses, and also in sluggish ulcerations. In 
acute cases, however, it generally proves 
too irritating to be of value. It has been 
employed mainly in gynecology and gen- 


ALUMNOL. 


565 


itourinary surgery, and, to a less extent, in 
general surgery, laryngology, and derma¬ 
tology. 

In ^ to 1 per cent, solution alumnol 
was found useful by Heinze and Liebreich 
in gonorrheal endometritis and in colpitis 
not of gonorrheal origin. Kontz, employ¬ 
ing alumnol in a series of 16 gynecological 
cases, found that cervical catarrh and 
simple perimetritis yielded to its repeated 
use, and that gonorrheal vaginitis was 
readily cured by it. In endometritis ac¬ 
companied by adnexal lesions, however, 
pain was augmented, owing to the irrita¬ 
tion. 

This author employed a 3 per cent, solu¬ 
tion for lavage, a 10 per cent, solution 
in the treatment of endometritis and ero¬ 
sions, and powders and bougies of 20 per 
cent, strength. Marfan used 3 per cent, 
bougies of alumnol in vulvovaginitis. 

Intra-uterine injections of the iodide of 
alumnol have been recommended by Gram- 
matikati as a substitute for curettement of 
this organ. 

Though alumnol has been claimed to 
exert a peculiarly destructive action on 
gonococci, its use as an injection in 
gonorrhea in the male has not led to re¬ 
sults commensurate with early expecta¬ 
tions. Casper employed it in 12 cases of 
acute gonorrhea, 20 chronic cases, 4 cases 
of gonorrheal epididymitis, 2 of post- 
gonorrheal adenitis, and 2 of soft chancre, 
administering intraurethral injections of 
0.25 to 2.0 per cent, solutions; he did not 
find it superior to other drugs in general 
use. Samter confirmed these findings, 
though Chotzen claimed to have obtained 
good results. In the cases of soft chancre 
in Casper’s series healing was promoted 
by the application of alumnol. Asch used 
a 10 to 20 per cent, solution for cauteriz¬ 
ing the lacunae and crypts at the urethral 
orifice. 

As a surgical antiseptic, alumnol is used 
in 0.5 to 3 per cent, solutions. In the 
dressing of wounds and in ulcerations, 
specific or non-specific, Eraud found it to 
produce no irritation or pain. As a desic¬ 
cant powder for wounds this author con¬ 
siders it efficacious. 

In nose and throat practice, alumnol has 
been found valuable in simple chronic and 
hypertrophic rhinitis, in ozena, in catarrhal 


and follicular tonsillitis, and in acute and 
chronic pharyngitis. It is used either in a 
1 per cent, solution as a douche, in a 
watery glycerin solution (1:5), to be ap¬ 
plied to the affected parts, or as a powder, 
mixed with Starch (10 to 20 per cent.), for 
insufflation. Stepanicz found that in acute 
laryngeal affections the roughness of voice 
generally disappeared after a single in¬ 
halation of a 1 per cent, solution. In 
chronic cases, insufflations of alumnol and 
starch (2 to 10 per cent.) also gave good 
resvdts. Metzerott used alumnol with 
satisfaction not only in laryngitis, pharyn¬ 
gitis, tonsillitis, and peritonsillitis, but also 
in edema, syphilis, and tuberculosis of the 
larynx. In a case of symptomatic laryn¬ 
geal edema, probably of syphilitic causa¬ 
tion, with a severe grade of s'tenosis, the 
administration of alumnol solutions in the 
form of injections and the steam spray 
made it possible to defer tracheotomy for 
six months. In the case of a singer 
troubled with subglottic laryngitis, with 
wave-like fluttering of the vocal cords, an 
alumnol spray gave early relief; also in 
one of chorditis nodosa (singer’s nodules), 
strong solutions of the remedy proved 
beneficial. 

In otology alumnol has also been em¬ 
ployed. In suppurative otitis media Heath 
noticed, however, that it sometimes caused 
persistent burning sensations, and that it 
tended to unite with pus in the exter¬ 
nal meatus to form stone-like pellets,—a 
peculiarity condemning its use in this 
disorder. 

In dermatology alumnol has been found 
serviceable in powder form (12 to 25 per 
cent), collodion (5 to 10 per cent.), and 
ointment (1, 5, and 121^ per cent). It has 
proven effective in dermatitis, acute eczema 
of all sorts, and chronic eczema, but in 
syphilis and the parasitic skin affections 
did not yield much benefit. In acne and 
acne rosacea as good results have been 
obtained with it as by most other methods 
of treatment. Chotzen found alumnol effi¬ 
cacious in acute and chronic inflammations 
of the skin and mucous membranes, in¬ 
cluding erysipelas, favus, lupus, soft chan¬ 
cre, and erosions. Eraud made the state¬ 
ment that alumnol appeared to be useful 
in certain varieties of pruritus, especially 
of the anus and scrotum. S. 


566 


ALYPIN. 


ALZHEIMER’S DISEASE. 


ALYPIN .—This is a white crystalline 
neutral powder, very soluble in water, 
which is not precipitated by alkaline fluids. 
Its properties are not impaired by boiling 
for 10 minutes. It was introduced as an 
anesthetic to replace cocaine. A 1 per 
cent, solution produced deep anesthesia of 
the rabbit’s cornea in 50 or 60 seconds. 
The lethal dose in dogs and cats is about 
double that of cocaine. It is relatively 
non-toxic and is a pure local anesthetic. 
It has been used in a 2 per cent, watery 
solution. When dropped into the con¬ 
junctival sac there is a slight smarting. 
In about 70 seconds the conjunctiva to¬ 
gether with the cornea is insensitive to 
touch. A few seconds later the ocular 
conjunctiva may be seized with fixation 
forceps without the patient experiencing 
pain. There is usually some dilatation of 
the superficial vessels, but no dilatation of 
the pupil. There is no interference with 
accommodation; it does not affect the cor¬ 
neal epithelium. 

Alypin has been lauded by several ob¬ 
servers, according to Wolff Freudenthal 
(Med. Record, July 20, 1912), but others 
assert that the anesthesia produced is very 
weak. It may be used for removal of en¬ 
larged turbinated bodies, since it does not 
cause, as does cocaine, a very marked con¬ 
traction of the hypertrophied turbinal 
tissues. 

Untoward Effects.—A. H. Miller (Jour. 
Amer. Med. Assoc., Jan. 17, 1914) reported 
103 cases in which alypin had been used as 
a local analgesic. Of these 35 were minor 
surgical operations and 69 genito-urinary. 
In 100 of the cases analgesia was per¬ 
fectly satisfactory, in 2 the analgesic 
caused serious difficulty and in one in¬ 
stance death. In the last case the patient 
was an apparently healthy adult, 39 years 
of age, who was about to undergo dilata¬ 
tion for stricture of the urethra. About 2 
drams (8 Gm.) of a 10 per cent, solution 
were introduced into the urethra and 
bladder. Two minutes later the patient 
had a general convulsion, followed by a 
half-dozen during the next 10 minutes, 
with cessation of respiration and arrest of 
the pulse. Artificial respiration and stim¬ 
ulation were tried without avail. In a 
'^cry similar case the patient was revived 
utter about 2 hours’ work. In a third un¬ 


toward case about 1^4 drams (6 Gm.) of a 
10 per cent, solution was introduced into 
the urethra and bladder for dilatation of 
a stricture. In 3 minutes the patient be¬ 
came unconscious, and respiration became 
embarrassed, but the pulse remained good. 
Artificial respiration and inhalations of 
oxygen brought this patient around in 
about 10 minutes. The author considers 
Bremmermann’s technique of depositing a 
tablet of alypin at the point of analgesic 
localization as far preferable to injecting 
an unmeasured quantity of the 10 per 
cent, solution into the urethra, at best a 
dangerous procedure. S. 

ALZHEIMER’S DISEASE.— 

Two cases of this rarely encountered 
mental disorder, both in men of 49, were 
reported by C. I. Lambert (Psychiatric 
Bull., Oct., 1916), both with a history of 
alcoholism. A most profound dementia 
developed slowly and insidiously in both. 
Inattention, indifference and absentmind¬ 
edness, declining efficiency, progressive 
impairment of memory, of retention, grasp 
and poverty of thought, followed by aim¬ 
less, restless, foolish behavior and increas¬ 
ing mental dilapidation which went on 
apace toward an apathetic dementia, in¬ 
capacity to comprehend, to talk, to walk; 
this was followed by a bedfast state in 
which the patient muttered and mumbled 
and fussed and fumbled, and pulled at his 
bedding, wet and soiled himself, chewed a 
little and gulped what was put in his 
mouth and vegetated for a time and died 
like a decerebrated animal. Among the 
more striking symptoms in these cases 
were the outstanding symptoms of ag¬ 
nosia, aphasia and apraxia. 

As a rule, in such cases, there is grad¬ 
ual development of severe dementia with 
signs of cerebral organic disease. With 
the dementia are focal phenomena causing 
aprasic, aphasia and asymbolic disorders. 

Alzheimer’s disease is distinguishable 
from cerebral arteriosclerosis owing to 
the fact that apoplectiform attacks do not 
take part in the development of the high 
grade dementia and focal symptoms. The 
morbid mental phenomena develop slowly 
and not paroxysmally, while the signs of 
arteriosclerosis throughout the system are 
generally absent. q 


AMAUROSIS (HANSELL). 


567 


AMAUROSIS. -DEFINITION. 

—Amaurosis, formerly used to desig¬ 
nate partial or complete blindness, 
has become, since the common em¬ 
ployment of the ophthalmoscope, 
much more limited in its meaning 
and application. At present, imper¬ 
fect vision not due to errors of 
refraction or visible pathological 
changes may be classified under 
‘"amblyopia”; complete blindness of 
one or both eyes and usually that 
form of blindness caused by disease 
of the nervous apparatus of sight, the 
retina, optic nerve, and cerebral centers 
under amaurosis. 

[Both words should be so used that they 
refer only to certain kinds of blindness which 
are to be described by a preceding adjective, 
and unless thus defined their meaning is 
vague and uncertain, carrying no suggestion 
of etiology or pathology. When the media 
of the eye are transparent, normal or abnor¬ 
mal conditions of the fundus are as easily 
diagnosed by the expert ophthalmologist as 
are diseases of the skin by the dermatologist; 
therefore, except as a convenience or as a 
substitute for the word blindness, amaurosis 
might well be omitted from ocular vocabu¬ 
lary. Eyes blinded by disease of or trau¬ 
matism to the middle or anterior third are 
seldom described as amaurotic eyes. H. F. 
Hansell.] 

Amaurosis in Brain Disease.— 
Tumors or other organic changes in 
the brain by which the optic tract is 
directly compressed or the ventricular 
fluid is forced into the optic nerve 
sheaths will produce blindness. The 
process is a mechanical one. In the 
former the optic nerve fibers in the 
tracts are directly compressed and 
deprived of their function; in the 
latter, the optic nerve is surrounded 
by fluid contained within a sac of 
only moderate distensibility. The 
gradually induced compression of the 
nerve induces arterial anemia and 


venous congestion of the nerve-head 
and retina, which is soon followed by 
serous and solid exudation into the 
distal extremity of the nerve. Finally 
the optic nerve fibers become atro¬ 
phied from stoppage of circulation 
and pressure of exudation. The loss 
of vision may commence in the pe¬ 
riphery of the field and advance by 
slow stages toward the center until 
finally the entire field is wiped out; 
or, as may be the case in apoplexy, a 
section of the field, one-half, one- 
quarter, or less, or the region about 
the fixation point and including it, is 
suddenly lost. Continuation or ex¬ 
tension of the brain lesion will'be fol¬ 
lowed by loss of the entire visual 
field. 

Amaurosis in Nephritis.—Disturb¬ 
ance of vision may be caused by 
hemorrhage or edema into the cere¬ 
bral centers, by pressure upon the 
chiasm or tracts, or by the action of 
the poison of uremia, by which the 
brain functions are held in abeyance. 
In the first and second it may affect 
one or both eyes and be partial or 
complete. In the third it comes on 
rapidly, involves both eyes, and dis¬ 
appears in a few hours or in a day or 
two. There are no ophthalmoscopic 
changes visible in the retinal circula¬ 
tion or structural alterations in the 
nerve or retina. The blindness is 
strictly cerebral. In the early stages 
of hemorrhage or edema the eye- 
grounds are normal; later they show 
the signs of intracranial pressure. In 
a man who died twelve hours after 
cerebral hemorrhage and who was 
unconscious from the time of the at¬ 
tack until his death, the ophthalmo¬ 
scope showed only moderate dilatation 
and tortuosity of the veins. These 
forms of amaurosis are not to be 


568 


AMAUROSIS (HANSELL). 


confounded with the amblyopia of 
albuminuric retinitis, in which the 
vision is affected in several ways; by 
edema of the nerve-head, edema of 
the retina, hemorrhage in the foveal 
region, and patches of degeneration of 
that area. The diagnosis may be estab¬ 
lished by the ophthalmoscope. 

The writer describes 3 patients who 
were blind for longer or shorter 
periods after blows on the back of 
the head that did not fracture the 
skull. He ascribes the blindness to 
a traumatic affection of the occipital 
lobes, shock or hemorrhage, or both. 
L. Newmark (Jour, of Ophthal. and 
Otolaryn., May, 1914). 

Case in which the blindness came 
on gradually first in one eye and 
after some time in the other. There 
had been lancinating pains and some 
tendency to ataxia for a few months. 
The patient was a man of 49, and 
there was no history of headache or 
ocular paralysis. A number of cases 
on record teach the necessity for 
curing the syphilis in the secondary 
stage at least as the only means to 
certainly ward off atrophy. L. D. 
Espejo (Cronica Medica, Nov., 1917). 

Amaurosis in Hysteria.—Neuroses, 
the result of an unknown derange¬ 
ment of the nervous system originat¬ 
ing within the body or of traumatism, 
may reduce or altogether destroy 
temporarily the visual power in one 
or both eyes, rarely the latter. The 
traumatism may be ocular or involve 
any other part of the body. In order 
to induce blindness or even amblyopia 
the causative disease or injury must 
affect an individual of peculiar or sus¬ 
ceptible organization and makes 
manifest a tendency toward magnifi¬ 
cation of trifles for the sake of bring¬ 
ing into prominence the ego or for 
the sake of imposition. In traumatic 
cases the diagnosis between hysteri¬ 
cal amaurosis and malingering is not 


always easy. Both offer no evidence 
externally or internally in the eye ofi 
any mark of injury or disease suffi¬ 
cient to account for the symptoms. 
In hysteria the well-known stigmata 
may be found—tubular field, transient 
and recurring ocular paralyses, re¬ 
versal of the color field, well-defined 
patches of localized anesthesia of the 
skin, inexplicable and transient pains 
distributed anywhere and everywhere 
in the body and created by cleverly 
directed interrogation. The majority 
of the subjects are women who are 
more or less mentally unbalanced by 
disease of the sexual organs or by 
physical or mental idleness. The ma¬ 
lingerer is usually a man who resorts 
to the excuse of blindness in order to 
avoid unpleasant or dangerous duty 
or to collect damages from a rich cor¬ 
poration. The symptoms of hysterical 
amaurosis are altogether subjective 
and of cerebral origin. The eyes 
cannot be held responsible. 

Amaurosis in Spinal Disease.— 
Primary atrophy of the optic nerves 
preceding or accompanying disease 
of the spinal cord and spinal nerves 
is a common affection. It is “pri¬ 
mary” because it is initiated and 
carried to its finish without inflam¬ 
mation of the optic nerve visible to 
the ophthalmoscope. There is no 
edema or exudation. The disk mar¬ 
gins remain clear cut and well de¬ 
fined. The first noticeable change is 
a loss of the normal pink color on the 
temporal half of the papilla and a 
diminution of the size of both the 
arteries and veins of the retina. 
Gradually the vascularity becomes 
less, the nerve becomes paler and 
finally white, all the fine vessels 
having become absorbed from the 
surface. Contemporaneously with the 


AMAUROSIS (HANSELL). 


569 


atrophic process the vision declines 
until complete amaurosis results. 
Early in the disease the field for 
colors is concentrically contracted or 
the perception of green is lost, and 
the retina becomes less sensitive to 
light or the optic nerve less capable 
of transmitting feeble stimulation. 
The affection is binocular, although 
one eye is usually more affected. 
Secondary atrophy, that following 
inflammation of the intraocular end 
of the optic nerve, presents entirely 
different ophthalmoscopic appear¬ 
ances, and no confusion need arise in 
the diagnosis between the two affec¬ 
tions. The diseases of which primary 
optic nerve atrophy is a prominent 
symptom are tabes, disseminated and 
lateral sclerosis, dementia paralytica, 
and paralysis .agitans. The pupillary 
and visual disturbances may .precede 
by many years the development of 
spinal affections, particularly posterior 
sclerosis, and many of the so-called 
idiopathic cases really belong to this 
class. The writer believes this is true 
also of paralysis agitans. He has at 
present a patient who seven years ago 
had incipient atrophy of the optic 
nerves with shallow excavation and for 
the past two years has slowly advancing 
paralysis agitans. 

Amaurosis following Hemorrhage. 
—After extensive loss of blood from 
any cause, but especially from disease 
of the stomach, intestines, or uterus, 
blindness affecting both eyes, com¬ 
mencing two or three days after 
the hemorrhage and advancing rap¬ 
idly, may ensue. The ophthalmoscope 
shows marked ischemia of the retina 
with low-grade edema of the nerve- 
head. The blindness may be complete 
and permanent, terminating in optic 
nerve atrophy; or, in an individual 


with good recuperative power or when 
the loss of blood has been moderate, 
restoration of sight may be complete. 

Amaurosis in Pregnancy.—Toward 
the completion of the term of preg¬ 
nancy or during confinement, vision 
may be entirely suspended in both 
eyes for some hours or days. The 
amaurosis is usually associated with 
convulsions or other signs of puer- 
pural septicemia. It should be re¬ 
garded as a strong indication of 
intense and general poisoning. The 
fundus either shows no deviation 
from the normal or the retinal veins 
are distended and dark in color, the 
nerve-head is slightly edematous, and 
an occasional hemorrhage is found in 
the retina. After safe delivery, vision 
rapidly returns and the eyes are 
restored to their previous condition. 
Atrophy of the nerve and permanent 
amaurosis as a result of pregnancy 
alone have not, as far as the writer 
knows, been described, yet he has 
seen cases in which no other cause for 
the blindness could be assigned. 

Case of amaurosis gradually develop¬ 
ing in the course of pregnancy. The 
first signs of optic neuritis were noted 
about the fourth month; both eyes were 
affected and external causes could be 
excluded. The optic nerve was atro¬ 
phied when the patient was first seen 
and the indications for interruption of 
the pregnancy were beyond question. 
Sight began to improve at once, and 
within two weeks vision was restored 
in the right eye. The other eye was 
first involved, and the nerve was 
atrophic beyond relief. The woman 
was a multipara of 37, with 8 children, 
and the author deemed it necessary to 
insure future sterility by an operation 
on the tubes. The case confirms anew 
the importance of immediate interrup¬ 
tion of the pregnancy in case of optic 
neuritis from this cause. Holzbach 
(Zentralbl. f. Gynak., May 23, 1908). 


570 


AMAUROSIS (HANSELL). 


A form of amaurosis or amblyopia, 
not accompanied by ophthalmoscopic 
signs, or, at least, by none adequate 
to account for the condition, may 
supervene during pregnancy, parturi¬ 
tion, or the puerperium. Rarely it 
may assume the form of a hemianopic 
defect or of a central scotoma in the 
fields of vision, and still more rarely 
of hemeralopia (night blindness). It 
is often associated with such signs 
and symptoms of toxemia as head¬ 
ache, edema, eclampsia, and scanty 
urine containing albumin, casts, and 
blood. Recovery occurs, as a rule, 
within a few hours or days. Stephen¬ 
son (Ophthalmoscope, March, 1910). 

Amaurosis from Fracture of the 
Skull. —Numerous cases have been 
recorded of complete blindness of 
both eyes some months after a trau¬ 
matism of the skull. The common 
lesion is fracture at the apices of the 
orbits with or without involvement of 
other bones at the base. Hemorrhage 
from rupture of a large blood-vessel 
either anteriorly at the base or in¬ 
volving the basal or cortical centers 
of vision, a frequent complication of 
fracture of the skull, will destroy 
vision. 

In the latter lesion the amauro¬ 
sis is more rapid in its onset and 
temporary. Absorption of the blood 
is followed by gradual return of vis¬ 
ion unless the nerve structures have 
been destroyed by the insult or by 
pressure. 

Description of an epidemic of tran¬ 
sient blindness. Of 5 persons on 
board a small vessel soon after its 
arrival, 3 were taken suddenly sick 
and complained of loss of vision, but 
there was no fever; 2 died within 3 
days, a man and a woman. The man 
who recovered became blind the 
fourth day. After 12 days of amaur¬ 
osis, vision gradually returned, al¬ 
though there were still evidences of 
optic neuritis. Three other cases of 
this apyretic amaurosis developed in 


the same locality, without contact 
with the first group. One of the men 
was just recovering from influenza. 
No causes of common intoxication 
could be discovered in the first group. 
Verger and Moulinier (Jour, de Med. 
de Bordeaux, Feb. 15, 1919). 

The writer urges that not a minute 
be lost before training those sud¬ 
denly blinded. Such a person is like 
a babe just born into a new world. 
From the very.first, while still in the 
eye hospital, his training in writing 
with a guide frame and in reading 
the Braille type should begin, with¬ 
out waiting to ascertain whether 
vision is entirely lost or not. All the 
men could read and even write the 
Braille fluently by the time they left 
his service and had been initiated into 
manual labor, such as weaving rugs, 
making brooms and brushes, resoling 
shoes, or doing light garden work. 
Ginestous (Prog. Med., June 8, 1919). 

Congenital and Hereditary Amau¬ 
rosis. —Infants born with ocular or 
cerebral defects, such as buphthalmus, 
microphthalmus, or other deformities, 
or ‘‘amaurotic family idiocy,” by 
which the essential parts of the eye 
or brain are wanting or so disturbed 
that function is absent, are hope¬ 
lessly blind. Hereditary optic nerve 
atrophy, transmitted usually to males 
through the female line, appears sud¬ 
denly between the twentieth and 
thirty-fifth year as a loss of central 
vision. The scotoma increases and 
the periphery of the field becomes 
contracted until the patient is per¬ 
manently and totally amaurotic. 

Having found in the family history 
of an inmate of the Missouri School 
for the Blind the presence of cataract 
in all the members of the family 
for at least five generations, the 
writer after receiving the opinions 
of 152 oculists concludes as fol¬ 
lows: 1. All whose life work brings 
them into relationship with the 
blind should be aware of the dan- 


AMAUROSIS (llANSELL). 


5/1 


gers connected with the marriage of 
a blind person. 2, The blind them¬ 
selves should be warned of the dan¬ 
ger to their children in case of mar¬ 
riage. 3. A distinction must be made 
between hereditary and non-heredi- 
tary forms of blindness. 4. Legal 
assistance should be invoked to pre¬ 
vent blind people from marrying. 5. 
This law should apply only to those 
cases of blindness in which heredity 
has been proved. With the exception 
of glaucoma and cataract, these dis¬ 
eases usually manifest themselves at 
or before the marrying age. 6. A law 
compelling every person to have an 
oculist’s certificate before marriage, 
though idealistic, would be imprac¬ 
ticable. 7. The general public should 
be educated in the dangers arising 
from hereditary blindness. C. Loeb 
(Annals of Ophthal., Jan., 1909). 

The causes of blindness in a series of 
1100 children are classified by N. B. Har¬ 
man (Brit. Med. Jour., Aug. 29, 1914) into 
3 groups: Injury or destruction of the 
cornea through surface inflammation with¬ 
in the eyeball or optic nerve; congenital 
defects of the eyes. Surface inflammation 
involved the eyes of 351 children, and of 
this number no less than 266 had ophthal¬ 
mia neonatorum, giving a proportion for 
this disease of 24 per cent, of the total 
cases of blindness. Only 47 cases were 
due to purulent conjunctivitis of later 
years, and 38 to phlyctenular keratitis. 
Syphilis was the cause of 190 cases of in¬ 
terstitial keratitis, of 126 cases of dis¬ 
seminated choroiditis or other blinding 
lesion of the posterior half of the eyeball, 
and of 16 cases of congenital blindness. 
Syphilis, therefore, accounted for a total 
of 343 cases of blindness, or 31.7 per cent, 
of the whole 1100 cases, or of considerably 
more than were due to gonorrheal infec¬ 
tion. This is in part the result of the 
recent more or less general use of some 
prophylactic agent in the eyes of the new¬ 
born to prevent gonococcic infection. 
Since 1904 the figures show that there 
has been a definite reduction in the pro¬ 
portion of cases of blindness due to the 
gonococcus, while the proportion due to 
syphilis has risen. 


In a study of the causes of blindness, 
H. L. Gowens (Hahn. Mthly, Apr., 1914) 
shows that 88.58 per cent, of all blindness 
is preventable as against 11.42 per cent, in¬ 
curable and non-preventable blindness. 
Even after eliminating purulent ophthal¬ 
mia and high myopia there still remains 
85 per cent, as a percentage of blindness 
which is conceded to be preventable 
blindness as against 15 as a percentage 
which is non-preventable and incurable. 

H. H. Stark (Jour. Amer. Med. Assoc., 
Oct. 30, 1915), in reporting cases of eye 
complications of sinus disease, reviews the 
literature. Of 88 cases reported, the optic 
nerve was involved in 52. Variations in 
the pupil occurred as one of the earliest 
symptoms. Exophthalmos occurred in 11, 
and involvement of the extrinsic muscles 
in 11. Central scotoma was the most defi¬ 
nite, and the one on which the author 
most relies. 

W. H. Bates (N. Y. Med. Jour., Feb. 3, 
1917) cites a case in which he employed a 
new method of treatment for a develop¬ 
ing glaucoma, and a previous gradual loss 
of sight for 25 years. The patient, a 
woman, had received treatment from 
many physicians for her eye conditions 
during this time. Bates treated her for 
the following conditions: Incipient catar¬ 
act, vitreous, cloudy with floating bodies; 
neuritis, with partial atrophy of the 
optic nerves; retinitis, with obliteration of 
many blood-vessels; choroiditis dissem¬ 
inata; glaucoma of the left eye; connective 
tissue in the anterior chamber of the left 
eye, obscuring the iris and pupil; func¬ 
tional myopia; functional divergent and 
vertical squint. An acute glaucoma de¬ 
veloped and was treated at first by drugs. 
With the assistance of Dr. C. Barnert an 
iridectomy was performed, and while pain 
and tension were relieved, the vision was 
not improved. Mild, recurrent attacks of 
glaucoma occurred. Bates then employed 
the central fixation method of treatment, 
and obtained such excellent results that 
the patient at the end of a comparatively 
short time was able to travel on the sub¬ 
way, attend social functions, and could 
see clearly the lights across the Hudson 
River. In 6 days the sight of the right 
eye had improved to more than Jlo of the 
normal. The method demands the use of 


572 


AMBLYOriA (llANSELL). 


the memory and the imagination. A small 
black spot on the Snellen card was 
imagined, and at the beginning of the 
treatment, the period imagined was im¬ 
perfect. The patient had to imagine this 
spot as perfectly black and stationary at 
all times; then to be conscious of seeing 
a part or all of a letter without losing the 
period. Central fixation meant to her a 
passive or relaxed condition of the eyes 
and brain. The objective symptoms all 
disappeared instantaneously when the pa¬ 
tient was conscious of central fixation, and 
the organic lesions were gradually seen to 
improve. With the blood-vessels the 
changes were more slow; but with the 
cloudiness of the lens, central fixation was 
followed immediately by an increased 
transparency. 

Howard F. Han sell, 

Philadelphia. 

AMBLYOPIA. — DEFINITION. 

—The word ‘‘amblyopia” signifies, 
without specializing the cause, that 
Ithe acuity of vision is below the nor¬ 
mal. The degree of the loss of vision 
is not suggested by the word itself, 
nor has there been any attempt, as 
far as I am aware, to define its lim¬ 
itations. It has been inherited from 
the preophthalmoscopic times, when 
the two words amblyopia and amau¬ 
rosis were commonly used, the former 
to mean dull vision and the latter, 
blindness. 

[Today we seldom hear of amaurosis, 
but we have tenaciously held to ambly¬ 
opia. Its use is convenient, but unless 
preceded by a descriptive adjective, such 
as toxic, hysterical, its meaning is indefi¬ 
nite and vague. The sense in which the 
word is properly used is the express par¬ 
tial loss of vision due neither to dioptric 
abnormalities nor to visible organic 
lesions, or, as expressed by the older 
writers, “amblyopia without ophthalmos¬ 
copic appearances.” It is, therefore, not a 
disease, but a symptom, and is due to 
many different and varied causes. H. F. 
Hansell.] 


The varieties of amblyopia are 
usually classified into organic from 
toxic and intracranial causes, func¬ 
tional exanopsia (disuse, non-use, 
argamblyopia) ; hysterical, simulated, 
and from exhaustion. 

Toxic Amblyopia.—The ingestion 
of or absorption into the system through 
the lungs, intestinal tract, or skin, of 
large quantities of certain substances 
without adequate elimination, or of 
small quantities in the case of some 
susceptible organisms, will produce a 
loss of vision varying in degree from 
slight up to total blindness. The com¬ 
monest agents are alcohol and tobacco 
in combination, lead, quinine, methyl 
alcohol, Jamaica ginger, coffee, mer¬ 
cury, phosphorus, chloral, opium, er¬ 
got, the salicylates, ptomaines. The 
sight is affected by these substances 
in several ways—by altering the con¬ 
stituency of the blood and lessening 
its nutritive value to the ocular struc¬ 
tures; by exciting disease of the re¬ 
tinal nerve-cells leading to degenera¬ 
tion of the cells and of the optic-nerve 
fibers connecting them with the brain- 
centers and inducing structural 
changes in the centers for vision. 
The amblyopia may be acute, as in 
quinine and methyl alcohol, or chronic, 
as in tobacco and alcohol poisoning. 

The symptoms common to the 
chronic form are :— 

Loss of Vision .—The deterioration 
is gradual and is usually neglected 
by the patient until the ability to read 
is diminished or abolished. Examina¬ 
tion shows that vision has fallen to 
one-half or more for distance and near 
and is not to be improved by glasses. 
The patient complains of a bluish-gray 
smoke or mist constantly before the 
eyes, and of partial night-blindness. He 
has no pain and rarely phosphenes or 


AMBLYOPIA (HANSELL). 


573 


other signs of irritation of the retina 
or nerve. 

Central scotoma^ either relative (col¬ 
ors only) or absolute. Early in the 
affection, probably contemporaneous 
with the beginning of the deterioration 
of vision, the perception for green in 
the small region of the field controlled 
by the fovea centralis is lost. Then 
follows the perception for red and 
possibly blue. The scotoma may be 
confined to these colors. Should the 
disease advance, the scotoma becomes 
absolute, the perception of all objects 
being lost in an area of about 10° 
from the fixation point. The periph¬ 
ery of the field retains its normal 
dimensions until the onset of optic 
nerve atrophy, when it undergoes a 
concentric narrowing. 

Papilla Changes .—The ophthalmo¬ 
scope shows in nearly all instances a 
whitening of the temporal half of the 
papilla, with retention of the normal 
coloring and vascularity of the nasal 
half. The retina and choroid are un¬ 
changed. Even the macula, the point 
of the fundus which is symptomatically 
most involved, appears healthy. In 
about one-third of the cases the optic 
disk is slightly hyperemic early in the 
disease and the vessels on the disk 
are veiled, reflecting the earliest sighs 
of optic neuritis. 

Acute poisoning from absorption of 
methyl alcohol, quinine, pure spirits, 
etc., causes sudden and complete blind¬ 
ness, even to the loss of perception of 
light. The action of the poison may be 
sudden or cumulative. A man of 35 
was exposed by the nature of his occu¬ 
pation to the fumes of varnish. He 
absorbed them through the lungs and 
the skin of the hands and arms. Feel¬ 
ing in his usual good health when he 
went to bed, he was awakened several 


hours later by some cause unconnected 
with his eyes and discovered he was 
totally blind. Examination of his eyes 
the following day disclosed excessive 
anemia of the disks. The arteries and 
veins of the retina were invisible a 
short distance from the nerve-head. A 
boy of 19 drank an unknown quantity 
of “white whisky” (95 per cent, alco¬ 
hol). He was blind the next morning 
and, except for the temporary return 
of perception of light lasting a few 
days, remained blind. The ophthalmo¬ 
scopic appearances were similar to 
those in the former case. The promi¬ 
nent symptoms of acute toxic amblyopia 
are illustrated by both cases: Sudden 
and complete blindness, partial tempo¬ 
rary recovery, ischemia followed by 
atrophy of the optic nerves and retinas, 
and permanent blindness. 

Amblyopia from Intracranial 
Causes.—In the preceding paragraph 
the morbid processes are presumed to 
be limited to the nervous mechanism of 
the eye, lying anterior to the chiasm or, 
if they invade the cerebral tissues, the 
involvement is secondary and may be 
considered as a complication. In the 
intracranial amblyopias the original le¬ 
sion is cerebral, the secondary in the 
optic nerves and retina. Uremia of 
Bright’s disease, of pregnancy, and 
of scarlet fever is a common cause. 
The amblyopia is usually binocular, 
rapid in its course, and leads often 
to complete, but temporary blindness. 
The prognosis is good. No changes 
in the eye-grounds commensurate 
with the degree of loss of vision are 
to be seen. The retinal veins are dis¬ 
tended, dark, and tortuous, and the 
edges of the disk veiled by edema 
of the nerve and adjacent retina. The 
cerebral vessels present a similar 
condition, namely, reduced supply of 


574 


AMBLYOPIA (HANSELL). 


arterial blood, venous stagnation, and 
diffused serous exudation into the brain 
substance. The foreign elements con¬ 
tained in the blood doubtless are a con¬ 
tributing cause to the disturbed brain 
functions. With the establishment of 
free secretion of urine or artificially 
induced active diaphoresis the poison is 
eliminated from the blood, the serum 
absorbed, and the vision and cerebration 
restored; or, the kidneys refuse to act, 
the skin cannot be stimulated, and death 
ensues. 

Rarer forms of amblyopia due to 
obscure intracranial lesions are the 
“crossed” and the “hemianopsias.” 
Mills says (Posey and Spiller) : “As 
the fibers of the macular bundles are 
undoubtedly distributed to the pre- 
geniculatum, complete destruction of 
this body, or .of a special portion of 
it, w^ould cause central amblyopia of 
the crossed variety.” In the hemian- 
opic variety one-half of the macular 
field is lost and the other half pre¬ 
served. Thus one-half of a word or 
other small object close'to the eyes 
is obscured and can be seen only by 
movement of the ball. In explana¬ 
tion Mills further says: “A strictly 
limited lesion of the calcarine cortex on 
the one hand and of the angular region 
on the other may cause blindness in 
half of the macular field of the cor¬ 
responding sides.” 

Hysterical Amblyopia.—The fea¬ 
tures characteristic of this affection are 
partial or complete blindness, monocu¬ 
lar or binocular, without discoverable 
changes in the ocular structures or 
signs in the eye or elsewhere in the 
body of organic disease of the brain or 
nervous system. The loss of vision 
may arise spontaneously, or appear at 
the termination of an attack of general 
hysteria, or be due to a slight trauma¬ 


tism to the eye or head. The trau¬ 
matism is, as a rule, slight and out 
of all proportion to the seriousness of 
the subsequent complaints. Amblyopia 
may be the only ocular symptom or it 
may be complicated by ptosis, recession 
of the near-point, pupillary inequalities, 
or disturbances in the field of vision. 
The alteration in the size and form of 
the field presents three possible fea¬ 
tures : concentric contraction, which is 
not in the least characteristic of hys¬ 
teria; reversal of the normal limits of 
the color fields, and the tubular field. 
Traumatic cases recover promptly and 
wholly after the cause, for instance a 
suit for damages, is removed. Cases of 
spontaneous origin and those dependent 
upon functional derangements of the 
nervous system are more persistent, 
often recur, continue weeks and months, 
and recover only upon the restoration 
to health of the individual. It must not 
be forgotten that blindness without 
ophthalmoscopic findings or evidence 
of disease of the cerebrospinal system 
may not always be diagnosed as hys¬ 
terical, and that it may have an organic 
cause to become manifest in time. To 
make the diagnosis positive it should be 
associated with at least some of the 
well-known stigmata of hysteria. 

Simulated Amblyopia.—The differ¬ 
ential diagnosis between simulated and 
hysterical amblyopia is rendered diffi¬ 
cult by the similarity of the two affec¬ 
tions and because both occur in the 
same class of patients, the neurotic and 
those of hypersensitive organizations. 
Pretended, feigned, or simulated blind¬ 
ness is found among recruits for the 
army and navy services, those who wish 
to escape positions in which danger or 
punishment may be incurred, and those 
who wish to create false impressions 
and exaggerated estimates of their 


AMBLYOPIA (HANSELL). 


575 


physical disabilities, especially in law¬ 
suits for damages. Simulated am¬ 
blyopia of both eyes is rare and detec¬ 
tion difficult. Reliance must be placed 
on the action of the pupils and the want 
of relation between the apparently nor¬ 
mal eyes and the symptoms. The mo¬ 
nocular form, however, may be, as a 
rule, easily detected. The ophthalmo¬ 
scope shows clear media and healthy 
eye-grounds; a strong spherical lens 
placed before the sound eye will prevent 
accurate vision in that eye beyond the 
focal distance of the glass; a prism of 
5°, base down or up, will give vertical 
diplopia; a prism of 10°, base out, will 
cause a manifest rotation of the eye 
inward, unconsciously made to fuse the 
horizontally induced double images; a 
lead pencil placed before the sound eye 
will not interrupt reading; the pupils 
respond to light and convergence almost 
uniformly. The tests will more suc¬ 
cessfully deceive the patient into admit¬ 
ting visual power in the assumed blind 
eye if his attention is directed by them 
to the sound eye. Radiography is also 
valuable in the diagnosis. An individ¬ 
ual may claim that the blind eye con¬ 
tains a fragment of glass or other 
foreign material impervious to the rays. 
In such cases a shadow is cast on the 
plate when the claim is true. In 
trolley accidents it frequently happens 
that the glass of the doors or windows 
is shattered and the hysterical or fraud¬ 
ulently inclined passenger asserts that 
he was blinded by the entry and reten¬ 
tion in his eye of glass. Examination 
with the ophthalmoscope cannot inva¬ 
riably exclude the presence of the 
foreign body, particularly when it has 
lodged in the ciliary region or when 
the media are clouded. 

Amblyopia Exanopsia .—From con¬ 
genital defects in the ocular structures. 


such as cataract, polar and lamellar; 
coloboma of the lens or uveal tract; 
persistent pupillary membrane; albi¬ 
nism. Rays of light are obstructed in 
their passage through the eye by the 
opaque media, they are not clearly 
focused on the retina by reason of 
irregular refraction, or they fall upon 
insensitive retinas or those unsupported 
by choroidal pigment. In these cases it 
is probable that early in life the retinal 
centers in the brain are active and do 
not, either by disease or congenital 
anomaly, contribute to the blindness. 
The cataracts may be removed and 
vision restored when the operations are 
performed at an early age. Later, when 
the brain-centers have been trained and 
the habits of special sense perception 
have been formed, operations, although 
surgically successful, do not materi¬ 
ally improve vision. 

From Defects of Refraction ,—In 
grades of hyperopia from 2 D. to 5 D. 
in childhood, binocular vision may early 
become unattainable. The child uncon¬ 
sciously, in order to obtain good vision, 
makes extraordinary claims on the ac¬ 
commodation. But the ciliary muscle 
(accommodation) is supplied by nerve 
power by the third or motor oculi 
nerve, which also supplies the muscles 
of convergence. Therefore, excessive 
stimulation of accommodation or that 
surpassing the normal relation between 
accommodation and convergence com¬ 
pels a proportionately equal degree 
of convergence. Since both eyes can¬ 
not converge simultaneously in dis¬ 
tant vision, one eye assumes the 
abnormal convergence and the other 
eye is used for fixation. Both eyes 
retain their normal power of rotation, 
but each becomes in a sense inde¬ 
pendent of the other: the one is used 
for seeing; the other squints. The 


S7C) AMENORRHEA 

former has been the better eye from 
tlie beginning, either by reason of 
less error of refraction or more per¬ 
ceptive retina. The latter gradually 
becomes amblyopic from disuse. The 
retina loses its sensibility, the optic 
nerve its conductility, and the cerebral 
centers their function. In some chil¬ 
dren no reason can be assigned for 
preference of one eye. The error of 
refraction may be no greater and the 
rotatory power no less in the squinting 
than in the fixing eye. Here we must 
assume that the fault lies in the retina, 
nerve, or brain. Improvement of vision 
may be obtained by the forced use of 
the eye and the compulsory activity of 
the cerebral center, but‘vision equal to 
that of the non-squinting eye is seldom 
or never acquired unless the usefulness 
of that eye is destroyed by accident or 
disease. Habit and the cultivation of 
the visual apparatus that accrues from 
habit can not be ignored. Should, 
however, the treatment for defective 
vision be instituted very early, before 
anesthesia of the nervous apparatus of 
the squinting eye has developed, an 
appreciable benefit may be gained by 
the use of the amblyoscope, closure of 
the fixing eye by bandage, or atro- 
pinization of that eye. 

Amblyopia from Exhaustion.—Am¬ 
blyopia in consequence of excessive 
indulgence in coitus or masturbation 
has been recorded. It is a purely 
nervous affection. Upon removal of 
the cause and the administration of 
strychnine the cure is generally rapid 
and complete. Sudden loss of blood in 
large quantities, occurring sometimes in 
intestinal ulceration, after delivery of 
the child in confinement, rupture of 
blood-vessels by ulceration or accident, 
may be followed in a few hours by 
temporary loss of vision. The ambly¬ 


(MONTGOMERY). 

opia becomes permanent only in cases 
of degeneration of the ganglion cells 
of the retina or of the fibers of the 
optic nerve. 

Howard F. Hansell, 

Philadelphia. 

AMENORRHEA. — D E FINI - 
TION. —Absence of the menstrual flow 
in women of a suitable age who are 
not pregnant. Suppression of menses, 
the menstruation having ceased through 
some local or remote disorder, is also 
termed amenorrhea. 

VARIETIES. — Amenorrhea may 
be complete, when the menstruations will 
have completely ceased; comparative, 
when it appears occasionally; primary, 
when the menstruation has not pre¬ 
sented itself at the age of puberty nor 
subsequently; secondary, when transi¬ 
tory or accidental, or, having already 
appeared, the menstruation ceases. 

SYMPTOMS. —No other symptom 
than absence of the menstruation may 
be present, or the monthly flow may 
be absent and the general attendant 
phenomena usually preceding men¬ 
struation occur. Frequently the pa¬ 
tient complains of headache, heat- 
flashes, fever, nausea and vomiting, 
and heaviness in the abdomen. Con¬ 
comitant nervous disorders may form 
the basis of acute manifestations, 
hysterical especially. When the 
amenorrhea is due to obstruction, 
whether congenital or acquired, the 
patient does not experience severe 
pain, but rather a continuous dull 
aching in the pelvis and over the 
sacrum, aggravated at the periods 
when the menstruation should occur 
by the symptoms above mentioned, 
known as menstrual molimina. 

Pure suppression of the menstrua¬ 
tion rarely causes symptoms, espe- 


AMEXORRIIEA (MONTGOMERY). 


577 


cially when the impending- general 
disorder is the cause of the amenor¬ 
rhea. 

The menstrual flow may be sub¬ 
stituted by a profuse leucorrhea which 
is thick, viscid, and of a yellow or 
greenish-yellow color. Remote symp¬ 
toms may present themselves, doubt¬ 
less of reflex origin. 

ETIOLOGY. —The discussion of 
the causes of amenorrhea is rendered 
difficult by our want of knowledge of 
the forces which produce the periodi¬ 
cal recurrence of menstruation. Pri¬ 
mary amenorrhea is g-enerally due to 
imperfect or insufficient develop¬ 
ment. In cold countries the individ¬ 
ual matures more g-radually and the 
menstrual flow appears later than in 
warm countries, where development 
is rapid, but where, also, women enter 
stag-es of decrepitude at an earlier 
date. Anatomical imperfections and 
anomalies, the absence of any of the 
genital org-ans, or a rudimentary or 
infantile uterus may thus account for 
the total absence of menstruation. 
Imperforate hymen is a frequent, 
though easily recognized, cause of 
amenorrhea. 

Whether we ascribe the periodi¬ 
cal occurrence of menstruation to 
nervous irritation, to the influence on 
the mucous membrane of the uterus 
of a superabundance of lime salts in 
the blood or to the chemical influence 
through the blood of a secretion of 
the corpus luteum, the causes of 
amenorrhea can be divided into four 
classes:— 

Many cases of amenorrhea are 
traceable directly to absence of cor¬ 
pus luteum owing- to the degenera¬ 
tion of unruptured follicles. This 
probably accounts for the good re¬ 
sults obtained in some cases from 
corpus luteum organotherapy. Emil 


Novak (N. Y. Med. Jour., June 17, 
1916). 

An increase in amenorrhea has 
been observed since the beginning 
o'f the war, in young girls who have 
reached puberty. Amenorrhea is not 
infrequent in cases where the condi¬ 
tions of life are changed at the time 
of puberty. In the present instance 
the change is one of diet. This dif¬ 
fers from the pre-war diet in poverty 
of flesh and fat. There is also a pro¬ 
longed physical and intellectual weak¬ 
ening. M. Graefe (Miinch. med. 
Woch., Ixiv, No. 18, 1917). 

Nervous Disorders. —Grief, anxiety, 
fright, and anger are as many possible 
primary causes, especially if the 
patients are poorly fed. According to 
Bloom, probably not less than 33 per 
cent, of women emigrants under 30 
years of age suffer from suppressed 
menstruation after a sea-voyage. 
Many have abdominal distention, and 
not infrequently girls have been in¬ 
nocently charged with being preg¬ 
nant. Obstinate constipation is a 
common symptom. The true etiology 
is largely psychical and neurotic. 

The causes of primary amenorrhea 
at puberty not due to congenital 
atresia may be distinguished into 
three varieties, viz.: 1. Cases with¬ 
out discoverable cause, in which the 
genital organs are apparently per¬ 
fectly normal. 2. Those due to some 
congenital defect. 3. Amenorrhea ac¬ 
companying some general disease, as 
diabetes or tuberculosis. In the first, 
local or general treatment may cause 
appearance of the menses, the prog¬ 
nosis in the other two varieties being 
unfavorable. The writer cites a case 
in which menstruation occurred after 
grafting of a healthy ovary from an¬ 
other subject in the uterine wall. 
V. le Larier (Paris Thesis; Zentralbl. 
f. Gynak., Nu. 35, 1905). 

Women who either greatly fear or 
greatly desire to become pregnant, 
newly married women, and women 


578 


AMENORRHEA 


(MONTGOMERY). 


who are confined in prisons or insane- 
asylums furnish a large proportion of 
the cases. Removal from country to 
city or vice versa, especially when 
coupled with nostalgia, is a prolific 
cause. On general principles, change 
in the mode of living or of climate, 
especially with an intervening sea- 
voyage, appears to frequently act as 
the etiological factor. 

Amenorrhea may be an early symp¬ 
tom of brain tumor and in acromegaly 
may precede every other symptom 
by several months and be followed 
by optic atrophy. 

General Affections.—Amenorrhea 
frequently occurs after a serious ill¬ 
ness, such as typhoid fever, eruptive 
fevers, mumps, pneumonia, or during 
the course of any chronic disease, 
diabetes, cancer, malaria, at the onset 
of severe syphilis. Intoxication of 
the system, as in morphinism, alco¬ 
holism, and hydrargyrism, is also a 
recognized cause. Syphilis is also 
thought capable of causing amenor¬ 
rhea. 

Lutaud, of Paris, reported 18 cases 
in which the morphine habit caused 
amenorrhea. It is usually complete 
and accompanied by loss of sexual de¬ 
sire, but the functions are re-estab¬ 
lished if the habit be broken. 

Three cases, aged from 28 to 42, in 
which amenorrhea persisting from 
six to eight years was probably due 
to syphilis. They all exhibited char¬ 
acteristic symptoms of tertiary syph¬ 
ilis, and were subjected to a rigid 
mercury and iodide treatment which 
resulted in the return of the men¬ 
strual flow. Meirowsky and Franken¬ 
stein (Deut. med. Woch., Aug. 4, 1910). 

The writer observed a case in 
which the amenorrhea was due to an 
X-ray examination. The patient, a 
girl of 14, robust and of a good fam¬ 
ily, had swallowed a needle, and was 


examined for hour with the 

X-rays, which entailed a severe der¬ 
matitis. Although she had been men¬ 
struating for nearly 2 years, she 
ceased to do so after the X-ray ex¬ 
posure. After 3 months she began 
to have severe headaches and at 
times abdominal pain, especially in 
the left flank. Ovarian treatment, 
mustard foot baths and purgatives, 
applied at the approximate menstrual 
dates failed to bring any result. 
Siquot (Rev. Med. del Rosario, Aug., 
1918). 

It may be consequent upon an acute 
or chronic surgical affection, a blow, 
or injury. Luxurious living and want 
of exercise, obesity, and excessive in¬ 
tellectual labor at the period of 
puberty, when not counterbalanced 
by fresh air and active exercise, may, 
retard the development of the genera¬ 
tive organs and thus induce the 
disorder. 

Blood Disorders and Wasting Dis¬ 
eases.—Anemia and idiopathic chlo¬ 
rosis, pernicious anemia, leukemia, 
and Hodgkin’s disease are the most 
prominent factors. The following 
causes of waste—and directly, there¬ 
fore, of amenorrhea—are also to be 
remembered: Hemorrhage, albumi¬ 
nous discharges; hemorrhage from 
piles, scurvy, purpura, and injury, as 
in hemophilia; hemorrhage from the 
stomach, as in gastric ulcer; from the 
lungs, or from the nose, and from a 
rare disease produced by a parasite 
in the duodenum: the Ankylostoma 
duodenale. Long-continued suppura¬ 
tion, albuminuria, chronic diarrhea, 
malignant ulcers, tubercular disease, 
all impoverish the blood, and so may 
cause anemia. All diseases That 
cause wasting of the body finally 
cause the menstruation to cease. 
Chief among these are phthisis, dia¬ 
betes, caries of bone, protracted or 


AMENORRHEA 


(MONTGOMERY). 


579 


febrile illness; anorexia nervosa, the 
patient wasting because she will not 
eat; and gastric ulcer. 

The occurrence of menstruation is 
associated with increased vascular ten¬ 
sion ; hence, any condition which de¬ 
creases tension will favor amenorrhea. 

Lesion of Genitourinary Organs. 
—Amenorrhea may be associated with 
any lesion of the genital tract, though 
less likely to occur in inflammatory 
conditions. Adhesions from pelvic 
peritonitis are an occasional cause of 
hyperinvolutions of the uterus and 
amenorrhea as a symptom. 

Atrophy of the ovaries, senile atro¬ 
phy following pregnancy, and cystic 
ovarian degeneration are among the 
less common etiological factors. A 
most complete examination of the 
pelvic organs, under ether, if neces¬ 
sary, should be made in such cases. 

Exposure to cold during menstrua¬ 
tion, by inducing congestion of the 
pelvic organs, is one of the most 
active exciting causes, especially 
when supplemented by a local chronic 
disorder. The most important condi¬ 
tion with which this disorder might be 
confounded is pregnancy. 

PATHOLOGY.— A pathological 
identity can hardly be attributed to 
amenorrhea, owing to its complex 
causes, the diverse physiological con¬ 
ditions peculiar to the cases, and the 
diathetic conditions that may be 
present. The fact that the true 
nature of menstruation itself is un¬ 
known adds another objection, and 
it may safely be said that ^he pa¬ 
thology of amenorrhea is that of the 
diseases causing it, until the local 
disorders brought about by each will 
have been determined. 

DIAGNOSIS. —Primary amenor¬ 
rhea—that is, total absence of men¬ 


struation—is usually due, as already 
stated, to the absence of one or more 
of the organs of generation. It must 
be distinguished from retention of the 
itienses due to atresia of the cervical 
canal, of the vagina, or of the vulva. 
In the latter case no menstruation has 
existed, but the general premonitory 
symptoms of menstruation have oc¬ 
curred, though followed by no men¬ 
strual flow. Cases in which one. or 
more of the organs are absent are not 
very infrequent, while cases of im¬ 
perforate hymen are comparatively 
common. 

PROGNOSIS. —Amenorrhea due 
to absence of any of the organs is, of 
course, incurable. The same may be 
said where the approach of the meno¬ 
pause or other conditions point to pre¬ 
mature senility of the uterus, which 
involves the inhibition of the men¬ 
strual period. Although amenorrhea, 
when due to a serious chronic disease, 
is usually cured with difficulty, hope 
may always be entertained when the 
causative disorder is not in itself a 
fatal one. Return of the menstrua¬ 
tion in any chronic disorder, when the 
blood presents its normal appearance, 
is an encouraging sign. 

TREATMENT. —No woman 
should be treated for amenorrhea 
until the possibility of its being 
caused by pregnancy has been elimi¬ 
nated, if necessary by a careful physi¬ 
cal examination. Not infrequently 
will pregnant women desirous of 
escaping the responsibilities of mater¬ 
nity seek a consultation with the hope 
that some drug shall be administered 
or instrument inserted which will ter¬ 
minate the condition. 

Amenorrhea should always arouse 
concern; it may be the first symptom 
of acromegaly, to which it stands in 


580 


AMENORRHEA 


(MONTGOMERY). 


about the same relation as ordinary- 
goiter does to exophthalmic goiter, the 
hypophysis cerebri being so often in¬ 
volved. The amenorrheic should 
take special pains to avoid chilling, 
especially of the feet, and every 
catarrhal affection should be treated 
with great care. Three such patients 
in the writer’s practice had previous 
sinusitis, commencing in 1 case at the 
time the menses became irregular. 
Special care should also be paid to 
treatment of syphilis in this connec¬ 
tion. Rosenberger (Zentralbl. f. in- 
nere Med., Feb. 25, 1911). 

Curetting was found to aid in the 
restoration of menstruation in a large 
number of 111 cases of amenorrhea. 
The uterine mucosa undergoes cyclic 
changes even without the menstrual 
hemorrhage. The scraps obtained by 
curetting show whether the mucosa 
is comparatively normal or atrophied. 
By this means the writers discovered 
in 5 cases in the uterine mucous mem¬ 
brane a tuberculous process which 
had never caused symptoms. Novak 
and Graff (Zeit. f. Geburtsh. u. 
Gynak., Apr. 5, 1921). 

It should be kept in mind that 
amenorrhea is a symptom, and its 
cause be diligently sought as a prelimi¬ 
nary measure to treatment. Drugs 
which are considered to exert an in¬ 
fluence in promoting the menstrual 
flow are known as emmenagogues, 
and are divided into two classes, 
medicinal and physiological. 

Severe physical shock or fright 
sometimes causes the menstruation 
to return suddenly. 

When the arrest of menstruation is 
due to exposure to cold, warm baths 
and vaginal injections, sinapisms to 
the thighs and calves of the legs, 
saline laxative and manganese-bin- 
oxide pills (2 grains each), 1 or 2 
after each meal, are frequently suc¬ 
cessful. This drug acts by increasing 
the vascularity of the pelvic organs. 


The permanganate of potassium, or 
the lactate, in 1-grain doses three or 
four times daily, after meals, act in 
the same manner. 

Potassium permanganate may be 
given daily until the catamenia ap¬ 
pear and complete their course, when 
the salt should be discontinued; it 
should be recommended four days 
before the access of the next period, 
and continued until the flow ceases. 
It is useful in girls who, on leaving 
the country and coming to town, suf¬ 
fer from arrested menstruation; also 
in the amenorrhea induced by sea¬ 
sickness and in the case of women, 
between 30 and 40, generally mar¬ 
ried, who while rapidly increasing in 
weight suffer from a diminished men¬ 
struation. Potassium permanganate 
is given up to 1, 2, or more grains in 
pill form thrice daily, after meals. 
The pills should be made after the 
following formula: Potassium per¬ 
manganate, gr. j; kaolin and petrol¬ 
eum cerate, in equal parts, q. s. Cer¬ 
tain observers deny that the per¬ 
manganate produces abortion, but 
some cases of abortion apparently 
due to the drug have been observed. 
(Practitioner, Feb., 1911). 

In the amenorrhea following sea- 
voyages the preparations of manganese 
and oxalic acid hold the first place. 

When the manganese preparations 
fail, santonin, 10-grain doses at bed¬ 
time, is especially valuable in chlo¬ 
rotic subjects. 

The general system should be in¬ 
vigorated by attention to diet, sleep, 
and clothing. Out-of-door life, light 
exercise, and sunlight are most im¬ 
portant. This is especially the case 
when there is rapidly increasing obesity. 
In the latter case the diet should be 
regulated, saline laxatives adminis¬ 
tered, or a cure at Marienbad recom¬ 
mended. The administration of thy¬ 
roid extract is especially effective in 
premature menopause from obesity. 


AMMONIA (SAJOUS). 


581 


and should be associated with active 
exercise. Stimulation of the ovaries 
and uterus by the faradic current is 
especially efficient in such cases. 

Cupping or scarifying the cervix is 
sometimes successful. These means 
increase the pelvic congestion and 
tend to counteract uterine or ovarian 
torpidity. 

Rudimentary organs or atrophy of 
the uterus, if not too great, should be 
treated by dilatation of the uterus 
with tents and stimulated by the 
faradic current. The introduction of 
a stem pessary which is to be worn 
for a number of months not infre¬ 
quently increases the growth of a 
rudimentary organ and establishes 
the function of menstruation. Exer¬ 
cise and nourishing food should also 
be given. Sea-bathing is of assistance 
in such cases. 

In amenorrhea due to infantile 
uterus the writer recommends hy¬ 
gienic and tonic measures; the uterus 
slowly dilated with graduated dila¬ 
tors; iodine or 95 per cent, phenol ap¬ 
plied to the endometrium; and later 
the insertion of a stem pessary and 
the careful administration of thyroid 
extract or corpus luteum, given con¬ 
tinuously over a considerable period 
of time. Loop (N. Y. State Med. 
Jour., Apr., 1917). 

The rheumatic diathesis occasion¬ 
ally plays a part as an etiological 
factor. In such cases the ammoniated 
tincture of guaiac, 1 dram in milk 
three times a day, or the tincture of 
colchicum root, 10 drops every three 
hours until the bowels become free, 
will sometimes restore arrested men¬ 
struation. The salicylate of sodium 
is also valuable in this connection. 
Apiol, 4 grains daily in 1-grain pills, 
for fifteen days, has given good 
results. Fuchsin has been highly rec¬ 


ommended as an effective drug in re¬ 
establishing the menstrual flow. 

Electricity is of great value, fara- 
dism, static electricity, galvanism, 
and galvanic intra-uterine pessaries 
being applicable according to the 
nature of the case. 

Extract of cows’ ovaries fresh cor¬ 
pus luteum has been used with success, 
(see Animal Extracts: Ovarian Or¬ 
ganotherapy). 

The writer reports 20 cases treated 
by hypodermic injections of pituitrin 
or hypophysin. He has seen no bad 
effects, and a sufficient number of 
cases have been cured or improved 
to make the treatment worth trying. 
Rushmore (Boston Med. and Surg. 
Jour., Mar. 2, 1916). 

E. E. Montgomery, 

Philadelphia. 

AMIDOACETPHENETIDIN 
HYDROCHLORIDE. See Pheno- 
COLL Hydrochloride. 

AMINOFORM. See Hexamethy- 
lenamine. 

AMMONIA. — Ammonia, chemi¬ 
cally NH3, is made in large quantities 
from coal gas by heating the ammo- 
niacal liquor with calcium hydroxide, 
thus conducting the gas formed through 
tubes containing charcoal. It may be 
conveniently obtained in smaller amount 
by heating an ammonium salt, such as 
ammonium chloride, with dry caustic 
soda (sodium hydroxide) or slaked lime 
(calcium hydroxide). It can be formed 
by the direct union of nitrogen and hy¬ 
drogen under the electric spark, and is 
widely produced in nature through the 
putrefaction of albuminous substances. 

PROPERTIES.—Ammonia is a 
transparent, colorless gas, having an 
extremely pungent odor and acrid taste. 
It is strongly alkaline in reaction, and 


582 


AMMONIA (SAJOUS). 


dissolves very readily (to the extent of 
700 volumes) in water, forming a strong 
solution designated as ammonium hy¬ 
droxide (sp. gr., 0.897 at 25° C., U. S. 

P.). 

PREPARATIONS AND DOSE.— 

The preparations of ammonia included 
in the U. S. Pharmacopoeia are as fol¬ 
lows :— 

Aqua ammonice (ammonia water, 
hartshorn), containing 10 per cent, by 
weight of ammonia gas; dose, 10 to 30 
minims (0.6 to 2.0 c.c.). 

Aqua ammonicE fortior (stronger am¬ 
monia water), containing 28 per cent, 
by weight of ammonia gas; used chiefly 
externally as a vesicant. 

Spiritus ammonice (spirit of ammo¬ 
nia), an alcoholic solution, containing 
10 per cent, of ammonia; dose, 10 to 30 
minims (0.6 to 2.0 c.c.). 

Spiritus ammonice aromaticus (aro¬ 
matic spirit of ammonia), composed of 
ammonium carbonate, 34 parts by 
weight; ammonia water, 90 parts by 
volume; oil of lemon, 10 parts; oils of 
lavender flowers and of nutmeg, of each, 

1 part; alcohol, 700 parts; water, enough 
to make 1000 parts. A nearly colorless 
liquid when fresh, but gradually becom¬ 
ing darker; dose, 30 to 60 minims (2.0 
to 4.0 C.C.). 

Linimentum ammonice (ammonia lini¬ 
ment), composed of ammonia water, 
350 parts by volume; alcohol, 50 parts; 
cottonseed oil, 570 parts; oleic acid, 30 
parts. Should be freshly prepared when 
wanted. 

The following non-official prepara¬ 
tions have also occasionally been used:— 

Fetid spirit of ammonia, composed 
of asafetida, 1 part; spirit of ammonia, 
21 parts; dose, 30 minims (2.0 c.c.). 

Camphorated ammonia liniment, com¬ 
posed of ammonia water, 30 parts; cam¬ 
phor liniment, 70 parts. 


Ointment of ammonia, composed of 
ammonia water, 17parts; lard,32parts; 
oil of sweet almonds, 2 parts. 

MODES OF ADMINISTRA¬ 
TION. —Ammonia is miscible in all 
proportions with water and alcohol. 
The most agreeable preparation for in¬ 
ternal use is the aromatic spirit, which 
should always be given well diluted with 
water. As a stimulating inhalation, the 
gas arising from ammonium carbonate 
(the ordinary “smelling salts”) is fre¬ 
quently employed; but this may readily 
be replaced by the simple ammonia wa¬ 
ter, or, if additional care is used, by the 
stronger ammonia water. The spirit 
and the water of ammonia have also 
been administered hypodermically, or 
even intravenously, as stimulants, though 
their action is but fleeting, and consid¬ 
erable local irritation may arise. In 
pneumonia and other dyspneic states a 
little ammonia water dropped into boil¬ 
ing water at frequent intervals will 
“soften” the atmosphere and greatly 
facilitate breathing. 

Externally, the stronger ammonia 
water may be applied in full strength 
as a vesicant, and the area under 
treatment should be covered with a 
watch-glass to prevent evaporation. 
For counterirritant effects,a 10 percent, 
aqueous preparation, such as the weaker 
ammonia water, or a stronger oily prep¬ 
aration, such as the official ammonia 
liniment, is suitable. In children with 
delicate skins these preparations should 
be further diluted. In spasmodic croup 
a little ammonia added to water and ap¬ 
plied to the child’s neck and chest by 
means of a cloth will often bring con¬ 
siderable relief, though much care is re¬ 
quired to have the fluid sufficiently di¬ 
lute and not to leave it on too long. The 
evanescence of the effects of ammonia 
resulting from its volatility requires 


AMMONIA (SAJOUS). 


583 


that its administration be frequently re¬ 
peated. 

IN COMPATIBLES.— Mineral or 
vegetable acids and acid salts, which 
ammonia neutralizes with the formation 
of neutral salts; salts of the alkaloids, 
which ammonia may cause to be precip¬ 
itated by combining with the acid radi¬ 
cal (thereby setting free the more or 
less insoluble pure alkaloid) ; chlorine, 
bromine, and iodine, with which ammo¬ 
nia combines to form corresponding 
salts; mercurial and most other metallic 
salts, with which ammonia forms in¬ 
soluble mixed salts or hydroxides. 

CONTRAINDICATIONS.— In 
acute inflammations of the stomach and 
in cases where the urine is abnormally 
acid the internal use of ammonia is to 
be avoided. In small children and in 
persons with a sensitive respiratory 
tract, the inhalation of ammonia fumes 
is likewise apt to be prejudicial, large 
amounts giving rise to a bronchitis. 

PHYSIOLOGICAL ACTION.— 
Local Effects.—Solutions of ammonia 
strongly irritate any tissues with which 
they may be brought in contact. Ap¬ 
plied to the skin, they act as rubefa¬ 
cients or vesicants, according to the con¬ 
centration of the preparation used and 
the length of time it is left on the tis¬ 
sues. On the mucous membranes, es¬ 
pecially the conjunctivse, the buccal and 
the respiratory mucosae, ammonia vapor 
acts primarily as a stimulant, exciting 
the local nerve-terminals, causing in¬ 
creased flow of glandular secretions, 
and, when concentrated, spasm of the 
glottis; when kept in contact for a 
longer time, ammonia preparations 
cause inflammatory changes which may 
result in local death of the tissues, fol¬ 
lowed by sloughing. The caustic action 
of ammonia is due, as is the case with 
other alkalies, to a combination with the 


tissue albumins, resulting in the forma¬ 
tion of alkali albuminates, and with the 
fats to form soaps. The great penetrat¬ 
ing power of ammonia, due to its vola¬ 
tility, renders it, when concentrated, 
one of the most deeply acting of corros¬ 
ives. 

Effects on Internal Use .—Nervous 
System .—^After being absorbed into the 
circulation, ammonia stimulates, for a 
short period, the medulla oblongata and 
the motor side of the spinal cord. The 
higher brain-centers are, if anything, 
slightly depressed. The spinal stimula¬ 
tion results in an exaggeration of re¬ 
flex activity and, with excessive doses, 
in convulsions. Succeeding the stage of 
stimulation, a secondary stage of de¬ 
pression of the medullary centers and 
spinal cord may occur with large doses. 

Circulation .—Ammonia stimulates the 
heart muscle, the vasomotor center in 
the medulla, and, to a less extent, the 
inhibitory (vagus) center, likewise in 
the medulla. These effects result mainly 
in a pronounced rise of the general 
blood-pressure. The heart beats more 
strongly, but its rate is frequently 
slowed. Excessive doses may lead to a 
secondary depression of both the heart 
and vasomotor mechanism. 

Respiration .—The respiratory centers 
in the medulla are strongly stimulated 
by ammonia. Both rate and depth of 
breathing are increased through its ac¬ 
tion. 

Secretions .—Ammonia and the am¬ 
monium compounds stimulate the flow 
of body secretions, especially the sweat, 
saliva, and mucous secretions. The dia¬ 
phoretic effect is believed to be wholly 
central, i.e., due exclusively to excita¬ 
tion of the sweat-center in the medulla. 
The other secretory effects are ascribed 
both to a central action and to a local 
effect on the gland-cells. 


584 


AMMONIA (SAJOUS). 


Digestive Tract .—Moderate doses of 
ammonia stimulate, like other alkalies, 
the gastric glands if taken before meals. 
After meals they neutralize the acids 
of the gastric juice. Large amounts of 
ammonia exert a corrosive action on the 
mucosae {v. Ammonia Poisoning). 

Absorption and Elimination. —Con¬ 
cerning the manner in which ammonia 
exerts its stimulating effect, there are 
still differences of opinion. Some claim 
that, after being rapidly absorbed, am¬ 
monia, circulating with the blood, stim¬ 
ulates the vital centers directly; others 
believe that the centers are stimulated 
mainly reflexly, as a result of the local 
irritation produced in the stomach. 

The researches of Magnus showed 
ammonia to be neither absorbed nor ex¬ 
creted by the lungs. Hence, in so far as 
its administration by inhalation is con¬ 
cerned, the stimulating effects of am¬ 
monia would appear to be due largely 
to peripheral sensory stimulation. 

When taken internally, on the other 
hand, ammonia is readily absorbed; but 
on reaching the blood-stream it rapidly 
undergoes a chemical change whereby 
it is converted into the relatively inert 
substance urea. Whatever direct stim¬ 
ulating action it may exert on the nerve- 
centers and heart is, therefore, quickly 
brought to an end. 

By the conversion into urea, the am¬ 
monium in ammonium hydroxide loses 
the characteristics of an alkali metal. 
For this reason ammonia does not in¬ 
crease the alkalinity of the body fluids, 
differing thus from the hydroxides of 
sodium and potassium, which cannot 
undergo the change referred to. 

The urea produced from the ammo¬ 
nia is naturally eliminated largely with 
the urine, which may be somewhat in¬ 
creased in amount owing to stimulation 
of the renal cells by the excess of urea. 


TOXICOLOGY. —The ingestion of 
strong solutions of ammonia results in 
corrosion or violent inflammation of 
the mucous membranes of the mouth, 
esophagus, and stomach, and in marked 
irritation of the larynx and trachea, 
owing to the penetration of ammonia 
vapor into the respiratory passages. 
The symptoms consist of violent pain 
in the mouth, throat, and abdomen; sali¬ 
vation ; vomiting, sometimes bloody, 
and, occasionally, purging. The intense 
irritation of the respiratory mucous 
membranes may cause, at first, a mo¬ 
mentary arrest of breathing and de¬ 
pressed heart action, as well as spas¬ 
modic contraction of the laryngeal and 
bronchial muscles. Later, the persist¬ 
ing laryngeal irritation causes intense 
local burning and a characteristic diffi¬ 
culty of respiration, due to actual edem¬ 
atous swelling of the glottis. Sudden 
death by asphyxia may result, though 
more frequently it is due to shock aris¬ 
ing from the pronounced local destruct¬ 
ive effects of the alkali, or to collapse, 
possibly owing to a secondary depress¬ 
ive effect of the drug on the heart and 
medullary centers. Convulsions, how¬ 
ever, are comparatively infrequent in 
ammonia poisoning, and this fact would 
tend to indicate that in the majority of 
cases the amount of ammonia absorbed 
is insufficient to cause violent direct ef¬ 
fects on the nerve-centers. 

The ultimate results in cases of am¬ 
monia poisoning can seldom be pre¬ 
dicted with certainty. Not only may 
laryngeal or bronchial inflammation fol¬ 
low, but the gastric mucosa may be so 
greatly injured as permanently to im¬ 
pair the functions of the stomach, and 
even cause death from inanition. More¬ 
over, in cases that recover from the 
acute effects, stricture of the esophagus 
is a frequent sequela. As with other 


AMMONIA (SAJOUS). 


585 


caustics, the upper and lower extremi¬ 
ties of the gullet and the point at which 
it crosses the left bronchus are the fa¬ 
vorite seats of corrosion. 

Large doses of ammonia (providing 
a sufficient amount is absorbed) are said 
to diminish the oxygen-absorbing power 
of the red blood-corpuscles and to inter¬ 
fere with coagulation. 

Treatment of Ammonia Poisoning. 
—The chief ends to be sought in the 
treatment of the first stage of the poison¬ 
ing are neutralization, dilution, and re¬ 
moval of the obnoxious agent. Vine¬ 
gar, lemon juice, or any other avail¬ 
able acid (preferably a vegetable 
acid), well diluted, should be given, 
together with a large amount of 
water. Where no acid is at hand, an 
oil, such as olive oil or linseed oil, 
forms the best substitute. The stom¬ 
ach-pump may then be cautiously 
used, though, if sufficient time for 
marked corrosion of the tissues has al¬ 
ready elapsed, its passage is attended 
with some danger, owing to the liability 
of the weakened tissues to perforation. 

Morphine should be given if the 
pain is severe, and tracheotomy may 
be required if asphyxia threatens. 

If symptoms of shock or secondary 
collapse appear, the usual measures for 
combating these states — hypodermic 
injections of ether, digitalis, atropine, 
strychnine; hot, strong coffee by the 
rectum; external heat, artificial respi¬ 
ration, etc.— should be availed of. 

Demulcents, such as olive oil, starch 
paste, tragacanth mucilage, milk, 
white of egg, or an infusion of elm 
bark, should be freely administered 
to soothe the infiamed mucous mem¬ 
branes. No food is to be given by 
the mouth for two days after the 
accident. 

Strictures of the esophagus should 


be treated by dilatation with bougies 
(v. Esophagus, Stricture of). 

APPLIED THERAPEUTICS OF 
AMMONIA.—As a Stimulant. —Am¬ 
monia is of great value as a rapidly 
acting “diffusible” stimulant, exerting 
a marked beneficial effect in all forms 
of acute circulatory, respiratory, and 
nervous depression. It may be admin¬ 
istered either by the mouth, by inhala¬ 
tion, or by hypodermic or intravenous 
injection. For internal use, the aro¬ 
matic spirit of ammonia, always well 
diluted, in doses of 15 minims to 1 
dram (1 to 4 c.c.), is the best prep¬ 
aration. For inhalation, ordinary am¬ 
monia water, or “smelling salts,” may 
be used. The effect'of ammonia, when 
it is taken internally, is believed by 
some to be chiefly reflex, varying in 
intensity with the degree of local irrita¬ 
tion produced. A similar mode of ac¬ 
tion is known to obtain when ammonia 
is inhaled; none of it is absorbed 
through the lungs, and the effect is cor¬ 
respondingly fugacious. The true stim¬ 
ulating effect of ammonia is best ob¬ 
tained by intravenous injection, though 
the hypodermic method is oftener em¬ 
ployed. 

In asphyxia, whatever be its origin, 
ammonia is a valuable agent. It may, 
with advantage, be given at once inter¬ 
nally and by inhalation. During the 
latter procedure care should be taken 
not to spill any of the strong liquid into 
the patient’s mouth or nose,—an acci¬ 
dent which is likely to occur when the 
patient is recumbent, and which is apt 
to yield a more pronounced effect, how¬ 
ever, than its ingestion. 

In cases of sudden heart-failure or 
collapse, as may result from the pres¬ 
ence of bacterial toxins or poisoning 
by depressant drugs, such as hydro¬ 
cyanic acid, chloroform, chloral by- 


586 


AMMONIA (SAJOUS). 


drate, aconite, etc., repeated ingestion 
of 15 minims to 1 dram of the aro¬ 
matic spirit of ammonia, diluted with 
half a tumblerful of water, or the in¬ 
travenous injection of like amounts of 
ammonia water, diluted with 6 drams 
of sterile water, will usually exert a 
powerful stimulating action. Ammo¬ 
nia may likewise be used internally to 
combat the effects of bites of poison¬ 
ous animals. 

In ordinary “fainting’’ and the 
lighter forms of shock, the inhalation 
of ammonia from its solution or from 
smelling salts may suffice to bring about 
the desired result. 

In infants, collapse occurring in 
summer diarrhea may be combated with 
occasional doses of a few drops of am¬ 
monia, well diluted. 

For the algid stage of cholera, am¬ 
monia internally and ether hypoder¬ 
mically, with simultaneous free admin¬ 
istration of alcohol, have been highly 
recommended by Giacich. Marked im¬ 
provement in the general condition was 
noted within two hours after the insti¬ 
tution of this mode of treatment, and 
over 50 per cent, of cases already in 
the algid stage are said to have recov¬ 
ered. 

In acute alcoholic intoxication, the 
ammonia preparations are consider¬ 
ably used. Lavage of the stomach, 
followed by the administration of 10 
drops of ammonia water in a half-tum¬ 
blerful of water, will often counteract 
promptly the effects of the alcohol. 
Ammonia has also been used with 
benefit in the treatment of delirium 
tremens (Butler). 

As an Antacid.—Internally, am¬ 
monia may be used to counteract 
gastric hyperacidity, indicated by 
such symptoms as acid eructations 
(“heartburn”) and flatulence. Par¬ 


ticularly where there are pronounced 
abnormal fermentative processes, re¬ 
sulting in the formation of vegetable 
acids, does ammonia appear to be effi¬ 
cient. A few drops (3 to 5) of the 
water of ammonia, or 10 drops of the 
aromatic spirit,.well diluted,will often 
give relief under these circumstances. 
It should be remembered that, al¬ 
though the ammonia introduced will 
tend to neutralize any acids present, 
the local irritation produced by it will, 
in addition, tend to stimulate the gas¬ 
tric glands and musculature. Hence 
the special degree of benefit obtained 
where there is flatulence and in cases 
where the gastric functions are weak¬ 
ened by general debility or excessive 
alcoholic indulgence. 

In poisoning by mineral acids, such 
as hydrochloric or sulphuric acids, well- 
diluted ammonia may be given as an 
antidote (though a less-irritating alkali, 
when at hand, is much preferable). 

Externally, in painful insect bites, 
ammonia may be used to neutralize the 
acid (frequently formic acid) intro¬ 
duced at the moment of stinging. Its 
antiseptic action is also helpful. 

As a Counterirritant, Rubefacient, 
or Cauterant.—Ammonia water ap¬ 
plied to the skin acts powerfully in re¬ 
lieving subjacent pain, though the su¬ 
perficial pain attending its use is not 
infrequently more severe than is the 
case with other counterirritants. 

In patients with kidney affections, in 
particular, it has been used as a vesi¬ 
cant in place of cantharides, which 
causes harmful renal irritation in these 
cases. It has the property of passing 
through the horny layer of the epider¬ 
mis without destroying it (as would 
other strong alkalies), and of inducing 
blister formation through irritation of 
the dermis. 


AMMONIUM (SAJOUS). 


587 


In bruises, chilblains, and other su¬ 
perficial lesions, ammonia liniment 
may be employed as a rubefacient. It 
sometimes relieves the milder forms 
of chronic rheumatism, including the 
joint manifestations and lumbago. 

The corrosive and antiseptic prop¬ 
erties of ammonia may be utilized 
with great advantage and convenience 
in treating the bites of carnivorous 
animals, venomous reptiles and in¬ 
sects. In snake-bites, for example, 
strong ammonia water may be applied 
directly to the wound, the general 
stimulating effect of ammonia being 
also availed of by giving an intraven¬ 
ous injection of 30 to 60 minims of the 
weaker solution in 6 drams of sterile 
water. In insect stings, the local ap¬ 
plication of ammonia water will often 
greatly reduce the pain or itching; es¬ 
pecially where a tendency to local in¬ 
fection exists, the antiseptic property 
of the remedy may be utilized with 
great benefit. The patient should al¬ 
ways be cautioned, however, to remove 
the ammonia when marked redness of 
the skin appears; otherwise, consider¬ 
able local injury is likely to result. In 
a case witnessed by the writers, the pa¬ 
tient had used it in the form of a com¬ 
press to treat a horse-fly bite. The large 
area thus “treated” resembled a burn of 
the second degree. Most people handle 
ammonia carelessly. 

In the “hair tonics” recommended 
in premature alopecia, ammonia wa¬ 
ter is considered a valuable ingre¬ 
dient. The aromatic spirit of am¬ 
monia is also used in various other 
affections of the scalp, including 
pityriasis, etc. 

C. E. deM. Sajous 

AND 

L. T. DE M. Sajous, 

Philadelphia. 


AMMONIUM.— A metal-like body, 
never yet isolated in pure form, but 
known, from the manner in which its 
compounds can be formed by the in¬ 
teraction of ammonia gas and acids, to 
have the chemical composition NH 4 . 
The compounds of ammonium greatly 
resemble those of potassium; hence the 
inclusion of ammonium in the group of 
alkali metals. The official salts of am¬ 
monium are the following:— 

Ammonii benzoas (ammonium ben¬ 
zoate) ; dose, 5 to 30 grains (0.3 to 2.0 
grams). 

Ammonii bromidum (ammonium bro¬ 
mide) ; dose, 5 to 30 grains (0.3 to 2.0 
grams). 

Ammonii carbonas (ammonium car¬ 
bonate) ; dose, 2 to 15 grains ( 0.12 to 
1.0 gram). 

Ammonii chloridum (ammonium 
chloride) ; dose, 2 to 30 grains (0.12 
to 2.0 grams). 

Ammonii iodidum (ammonium io¬ 
dide) ; dose, 3 to 15 grains (0.2 to 1.0 
gram). 

Ammonii salicylas (ammonium sali¬ 
cylate) ; dose, 3 to 15 grains ( 0.2 to 
1.0 gram). 

Ammonii valeras (ammonium vale¬ 
rianate or valerate); dose, 2 to 10 
grains ( 0.12 to 0.6 gram). 

Ammonium acetate is official in 
liquor ammonii acetatis (spirit of Min- 
dererus), a solution of diluted acetic 
acid nearly saturated with ammo¬ 
nium carbonate; dose, 4 fluidrams 
(16 C.C., containing about 15 grains 
or 1 gram of ammonium acetate), 
and in liquor ferri et ammonii acetatis 
(Basham’s mixture), which is made 
up of tincture of ferric chloride, 1 
fluidram (4 c.c.) ; diluted acetic acid, 
1 % fluidrams (6 c.c.) ; solution of 
ammonium acetate, 12 % fluidrams 
(50 c.c.) ; aromatic elixir, 3 fluidrams 


588 


AMMONIUM (SAJOUS). 


(12 c.c.)‘, glycerin, 3 fluidrams (12 
C.C.), and water, enough to make 25 
fluidrams (100 c.c.) ; dose, 4 fluidrams 
(16 C.C.). 

PHYSIOLOGICAL ACTION.— 

The effects of the compounds of am¬ 
monium are a composite of those of the 
ammonium group or ion itself, and of 
the acid group in union with it. The 
latter may not only modify that of the 
ammonium, as in ammonium bro¬ 
mide, but may completely overshadow 
it, as in ammonium arsenate. 

The effects of the ammonium ion, 
when it enters the circulation, are, in 
general, those of a promptly acting, but 
fleeting stimulant. If the amount in¬ 
troduced be excessive, depression may 
follow the primary stimulation. 

In the nervous system the stimulat¬ 
ing effects of ammonium bear chiefly 
upon the spinal cord and medulla. The 
motor spinal centers are excited to in¬ 
creased activity, exaggerated reflex ac¬ 
tion, and even convulsions, being among 
the most evident results. The cere¬ 
brum, however, is, if anything, de¬ 
pressed rather than stimulated. The 
circulation is influenced in various 
ways: 1 . Stimulation of the vaso¬ 
motor center in the medulla causes 
a rise of blood-pressure through 
constriction of the peripheral blood¬ 
vessels. 2. The heart muscle is 
directly stimulated, the result being 
a strengthening of its beats and 
further rise in the blood-pressure. 3 . 
Excitation of the vagus (inhibitory) 
center in the medulla may cause some 
slowing in the heart rate. Respiration 
is accelerated and deepened through 
stimulation of the medullary centers 
presiding over this function. The body 
secretions, especially the sweat, saliva, 
and mucous secretions of the alimen¬ 
tary and respiratory tracts, are in¬ 


creased by ammonium, partly through 
stimulation of the nervous centers gov¬ 
erning secretory processes (exclusively 
so in case of the sweat secretion), and 
partly owing to local effects on the se¬ 
creting cells. 

Though most of the ammonium com¬ 
pounds are readily and promptly ab¬ 
sorbed from the stomach and intestines, 
their excretion through the urine and 
other secreted fluids is so rapid as to 
greatly limit the power and duration of 
their effects when taken by the mouth. 
Further, certain of the salts of ammo¬ 
nium, i.e., the acetate and citrate, when 
absorbed, are oxidized to ammonium 
carbonate in the system, and this, in 
turn, undergoes a rapid decomposition, 
probably mainly in the liver, whereby 
it is converted into urea. The ammo¬ 
nium group is thus destroyed, and its 
specific effects promptly disappear. 
Only by intravenous injection of rather 
considerable amounts of ammonium 
salts are the effects of the NH 4 group 
obtained with any degree of intensity. 

The decomposition of the NH4 group 
into urea involves loss of the alkaline 
properties of its compounds. For this 
reason the alkalinity of the blood is not 
increased and the acidity of the urine 
not diminished by the administration of 
alkaline salts of ammonium, as they 
would be by giving alkaline salts of so¬ 
dium and potassium. 

Ammonium salts which are not 
changed to the carbonate and elimi¬ 
nated as urea— e.g., ammonium chlo¬ 
ride—are excreted as neutral salts, and, 
therefore, also fail to influence the re¬ 
action of the urine. 

The contrast between the stimulating 
action of ammonium hydroxide (am¬ 
monia) or ammonium carbonate and 
the almost complete absence of it in the 
case of ammonium chloride is now be- 


AMMONIUM (SAJOUS). 


589 


lieved to be due not to any greater ra¬ 
pidity of absorption or more prolonged 
persistence of ammonium in the blood 
(the reverse being, in reality, the case), 
but to the reflex stimulation caused by 
the caustic alkaline action of the first- 
mentioned two compounds on the gas¬ 
tric mucosa (or wherever else brought 
into relation with the organism), as 
compared to the low degree of local ir¬ 
ritation caused by the practically neu¬ 
tral chloride of ammonium. 

As already mentioned, some of the 
ammonium compounds owe their 
therapeutic value chiefly to the acid 
group—benzoate, bromide, salicylate, 
etc.—with which the ammonium is in 
combination. For information con¬ 
cerning these the reader is referred to 
the headings under which the respect¬ 
ive acids are considered: Benzoic 
acid, bromides, salicylic acid, etc. The 
more important of the compounds in 
the physiological action of which the 
ammonium group plays the leading 
part will be treated of in the following 
sections. 

AMMONIUM ACETATE.— Am¬ 
monium acetate (CH 3 . COONH 4 ) oc¬ 
curs as a white crystalline solid, freely 
soluble in water. It is seldom used in 
its natural state, but enters into the 
composition of the official liquor am- 
monii acetatis (spirit of mindererus), 
which is extensively employed. This 
fluid is prepared by neutralizing dilute 
acetic acid with ammonium carbonate 
(5 grams of the former in 100 c.c. of 
the latter, according to pharmacopeial 
directions), the result being a colorless 
liquid, which may give off a faint odor 
of acetic acid, and has a mildly saline, 
acidulous taste and an acid reaction. 
The preparation is required to contain 
not less than 7 per cent, of ammonium 
acetate, and should be freshly prepared 


when wanted. The dose of spirit of 
mindererus is 2 fluidrams to 1 ounce 
(8.0 to 30.0 C.C.), repeated every two or 
three hours. 

Liquor fcrri et ammonii acetatis 
(Basham’s mixture) will be considered 
among the preparations of iron. 

MODE OF ADMINISTRATION. 
—Liquor ammonii acetatis is best ad¬ 
ministered well diluted in sweetened 
water. Sparkling water (charged with 
carbon dioxide) is also advantageous as 
a diluent. 

INCOMPATIBLES. —Strong 
acids, which enter in combination with 
the ammonium, replacing the weaker 
acetate radical; compounds of bases 
stronger than ammonium (sodium, po¬ 
tassium), with acids weaker than acetic 
acid, c.g., the carbonates of sodium and 
potassium; lime water (calcium hy¬ 
droxide) ; metallic salts, such as 
those of silver and lead. 

PHYSIOLOGICAL ACTION.— 
Ammonium acetate, especially when 
given in the official solution, is the most 
strongly diaphoretic of the salts of am¬ 
monium. Its action is believed to take 
place largely, if not solely, through 
stimulation of the sweat-center. The 
diaphoresis occurring under its influ¬ 
ence is greatly assisted if the cutaneous 
vessels are already in a state of dilata¬ 
tion or are caused to dilate by the ap¬ 
plication of warmth—blankets—to the 
patient’s skin, or by combination with 
sweet spirit of niter or aconite. 

A second useful property of this salt 
is its action as a diuretic. This ac¬ 
tion is exerted most strongly when 
diaphoresis is held in abeyance, i.e., 
when the skin vessels are not dilated. 
The diuretic effect of ammonium ace¬ 
tate is not produced through irritation 
of the kidney-cells. This is one of the 
ammonium salts which are rapidly con- 


590 


AMMONIUM (SAJOUS). 


verted in the system, first into ammo¬ 
nium carbonate, then into urea; hence 
the diuretic efifect is probably chiefly 
that of urea,—a normal stimulant to the 
renal function. 

Ammonium acetate is believed to be 
one of the most rapidly absorbed of the 
ammonium salts; we should, therefore, 
expect that some of the stimulating ac¬ 
tion of ammonium on the medullary 
nerve-centers and circulation would be 
exerted on ingestion of this salt. Such 
stimulation does not, however, with the 
exception of the sweat-center, appear 
to occur to any marked extent. The 
reason for the special preponderance of 
diaphoresis in the action of this salt of 
ammonium is not definitely known. 

THERAPEUTICS.—As a Diapho¬ 
retic and Diuretic.—The solution of 
ammonium acetate is useful as a mild 
sweat-producer and diuretic in febrile 
diseases, including acute coryza, in¬ 
fluenza, mumps, the eruptive diseases 
of childhood, etc. The elimination of 
toxic products, in which the skin, as 
well as the kidneys, plays so important 
a part in these affections, is hastened 
by it. It also tends to reduce excess¬ 
ive temperatures by increasing the 
amount of fluid evaporated from the 
skin. In the diseases of childhood, 
when the eruption is delayed, am¬ 
monium acetate will favor its ap¬ 
pearance. It has also been found 
serviceable in muscular rheumatism 
(Butler). 

In acute alcoholic intoxication am¬ 
monium acetate has been found to re¬ 
move promptly the symptoms. In 
migraine, too, through some obscure 
mode of action, and in amenorrhea, 
the remedy has sometimes proved 
beneficial (Butler). 

Externally, solutions of ammonium 
acetate have been applied as a lotion 


over contusions, beginning abscesses 
and glandular enlargements, and cer¬ 
tain skin diseases, c.g., prurigo. In 
chronic ophthalmic inflammations, 
also, it has been used as an eye-wash, 
a little laudanum being added to the 
acetate solution in order to relieve 
local discomfort. 

AMMONIUM CARBONATE.— 

The substance used under this name is 
not the pure carbonate of ammonium, 
(NH 4 ) 2 C 03 , but is a mixture in va¬ 
riable ratio of acid ammonium bicar¬ 
bonate, (NH4)HC03 or CO(OH)- 
ONH4, and ammonium carbamate, CO- 
(NH2)0NH4. This mixture is also 
known as ammonium sesquicarbonate, 
hartshorn, sal volatile, Preston salts, or 
bakers’ ammonia. It is made by heat¬ 
ing an ammonium salt, such as the chlo¬ 
ride, with chalk (calcium carbonate), 
and occurs in white, hard, translucent 
masses having a sharp, saline taste, a 
strong odor of ammonia, and a strongly 
alkaline reaction to litmus. It loses 
both ammonia gas and carbon dioxide 
when exposed to the air, and effloresces, 
becoming opaque and friable. When 
heated it volatilizes completely. When 
dissolved in hot water it is decomposed, 
ammonia and carbon dioxide being 
driven off; upon further boiling it dis¬ 
appears from the solution by volatiliza¬ 
tion. It is soluble in 5 parts of water 
at a temperature of 15° C. (59° F.), 
and in 4 parts at 25° C. (77° F.). Al¬ 
cohol dissolves only its carbamate con¬ 
stituent, the acid carbonate remaining. 
In glycerin it is soluble to the extent of 
1 in 5 parts. The purity standard set 
for ammonium carbonate by the United 
States Pharmacopoeia is that it should 
contain 97 per cent, of the constituents 
above mentioned, and should yield not 
less than 31.58 per cent, of ammonia 
gas. 


AMMONIUM (SAJOUS). 


591 


The dose of ammonii carbonas is 2 
to 15 grains (0.12 to 1.0 gram), the 
average being 5 grains (0.3 gram). 

The aromatic spirit of ammonia 
(spiritus ammonicB aromaticus), already 
considered under ammonia (q-v.), con¬ 
tains about 4 per cent, of ammonium 
carbonate. 

MODE OF ADMINISTRATION. 

—Ammonium carbonate should not be 
given in any form other than a well- 
diluted solution, thus avoiding excessive 
gastric irritation and facilitating absorp¬ 
tion. The evanescence of the effects of 
this salt, in common with other ammo¬ 
nium salts, requires that it be frequently 
repeated, e.g., every two hours. Its un¬ 
pleasant taste may be covered by lico¬ 
rice. 

INCOMPATIBLES. —Ammonium 
carbonate is incompatible with acids, 
with acid salts, and with lime water. 

PHYSIOLOGICAL ACTION.— 
Ammonium carbonate possesses, to a 
certain extent, the stimulating proper¬ 
ties of ammonia. As has already been 
stated, the general stimulant effect of 
the latter, taken internally, is now be¬ 
lieved due not so much to a direct ac¬ 
tion of the ammonium group on the 
nerve-centers and circulation after ab¬ 
sorption as to the irritation of the gas¬ 
tric mucous membrane due to the 
strong alkalinity of ammonia. The 
same view is held with regard to am¬ 
monium carbonate, the lesser extent of 
its stimulating effect corresponding with 
its lower degree of alkalinity as com¬ 
pared to ammonia. Taken in consider¬ 
able amounts, the salt causes vomiting. 

If ammonium carbonate is injected 
subcutaneously or intravenously, direct 
stimulation of the respiratory and vaso¬ 
motor centers, spinal cord, and heart 
by the ammonium circulating in the 
blood (in addition to the reflex srimu- 


lation from local irritation, when in¬ 
jected subcutaneously) is produced. 

Like the acetate of ammonium, the 
carbonate acts as a mild diaphoretic 
and diuretic. It possesses also, to a 
considerable degree, the property of 
increasing the bronchial secretions 
and mucus in general. After absorp¬ 
tion it is partly oxidized to urea; but 
some of it is excreted unchanged by 
the bronchial and other glands, which 
are stimulated by it. According to 
Sollmann, ammonium salts in increas¬ 
ing secretions of the respiratory tract 
and the saliva act in no less than four 
ways: 1. By reflex stimulation from 
the mucous membranes with which 
the salt is brought in contact. 2. By 
direct stimulation of the secretory 
nerve-centers, which the drug reaches 
through the circulation. 3. By a local 
stimulating action on the giand-cells 
themselves, with the secretions of 
which the salt is excreted. 4. Through 
liquefaction of the mucous secreted, 
owing to the alkalinity of the am¬ 
monium carbonate eliminated with it. 
(Several ammonium, salts, besides the 
carbonate itself—the acetate, citrate, 
etc.—are converted in the system into, 
and partly eliminated as, the carbonate.) 

Ammonium carbonate, like ammonia, 
is, to a certain extent, antiseptic, owing 
to its alkalinity. Applied to the skin, it 
acts as a rubefacient. 

The pure neutral carbonate of am¬ 
monium—(NH 4 ) 2 C 03 —is of physio¬ 
logical importance. The nitrogenous 
waste product of the activity of mus¬ 
cles is ammonium lactate. This, ac¬ 
cording to the belief of some, is con¬ 
verted in the tissues into ammonium 
carbonate, which, in turn, is dehydrated 
in the liver to ammonium carbonate, 
and, finally, to urea. Where the hepatic 
functions are deficient, ammonium car- 


592 


AMMONIUM (SAJOUS). 


bonate or carbamate may persist, and 
cause symptoms of ammonium poison¬ 
ing, somewhat resembling those of 
uremia. 

TOXICOLOGY.—Ammonium car¬ 
bonate, ingested in large amount, brings 
about nausea and vomiting through 
local irritation. If brought in contact 
with the mucous membranes -in concen¬ 
trated form, destructive lesions, some¬ 
what similar to those produced by am¬ 
monia, may result. For symptoms and 
treatment the reader is referred to the 
section on the toxicology of ammonia. 

THERAPEUTICS.—As an expec¬ 
torant, ammonium carbonate is of 
considerable value. The secretions 
are both increased and rendered more 
fluid, being, therefore, removed with 
greater facility. In bronchitis, pneu¬ 
monia, asthma, and pulmonary tuber¬ 
culosis, the combination of the ex¬ 
pectorant effect with the stimulating 
action on the respiratory centers is very 
advantageous, more especially in cases 
where dyspnea is marked. In these af¬ 
fections it should be given in doses of 
5 or 10 grains (0.3 to 0.6 gram), re¬ 
peated every two hours. 

In acute coryza it may also be em¬ 
ployed with satisfactory results. 

As a Stimulant. —The stimulating 
effect of this remedy on the medullary 
centers and heart is of great value in 
all conditions of general adynamia, 
with or without involvement of the 
respiratory tract. In the acute exan¬ 
themata of children, and continued 
fevers of various kinds, it may be used 
with great advantage to sustain cir¬ 
culatory and respiratory activity. In 
bronchopneumonia, chronic bron¬ 
chitis with marked general weakness, 
it is a favorite remedy. In chronic 
heart disease with failure of compen¬ 
sation it is also frequently used. The 


effect is, of course, of brief duration, 
and frequent administration being re¬ 
quired to keep up the action. In “faint¬ 
ing” (syncope) and shock the inhala¬ 
tion of “smelling salts” (ammonium 
carbonate reinforced with ammonia 
water) is a time-honored and effective 
procedure. 

As a Gastric Stimulant or Emetic. 
—In indigestion due to general weak¬ 
ness, and in cases where flatulence is 
a prominent symptom, ammonium 
carbonate may be used to tone up the 
gastric functions. Its effects are, 
however, evanescent. In the indi¬ 
gestion of alcoholics it has also proven 
very useful. 

Emesis may be obtained by the ad¬ 
ministration of large doses, e.g., 30 
grains (2 grams), of ammonium car¬ 
bonate. The absence of concomitant 
depressing effects distinguishes this 
form of emesis from that caused by de¬ 
pressing drugs, such as tartar emetic. 

As a Rubefacient and Discutient.— 
Ammonium carbonate may be em¬ 
ployed as a rubefacient in a manner 
similar to ammonia {q.v.). In psori¬ 
asis, baths containing ammonium car¬ 
bonate are given for the purpose of dis¬ 
solving off the scaly coverings of the 
lesions, in order that the local remedies 
subsequently applied may act directly 
on the skin. 

AMMONIUM CHLORIDE, also 
known as “sal ammoniac” or muriate 
of ammonia, has the chemical formula 
NH4CI. It may readily be produced 
by the interaction of ammonia and 
hydrochloric acid, but is.more usually 
produced by neutralizing ammonia with 
sulphuric acid, separating by crystalli¬ 
zation the ammonium sulphate thus 
formed, and subliming it with sodium 
chloride. It occurs as a white, crystal¬ 
line powder, odorless, but having a cool- 


AMMONIUM (SAJOUS). 


593 


ing, saline taste. In contrast with am¬ 
monium carbonate, ammonium chloride 
is permanent in the air. When strongly 
heated it is completely volatilized, with¬ 
out decomposition. 

Ammonium chloride is soluble in 2 
parts of water, in 50 parts of alcohol, 
and in 5 parts of glycerin at 25° C. (77° 
F.), and in 1 part of boiling water. 
Though ammonium chloride is a neu¬ 
tral salt, its solution in water has a 
slightly acid reaction. This is due to 
the fact that small amounts of NH4OH 
and of HCl are formed in the solution 
by reaction of NH4CI with H2O, and 
that the HCl is dissociated into its ions 
to a greater degree than the NH4OI-I, 
therefore being chemically more active 
and producing the acid reaction. 

The dose of anmionii chloridum is 
2 to 30 grains (0.12 to 2.0 grams), the 
average being 7y^ grains (0.5 gram). 
The trochisci ammonii chloridi (tro¬ 
ches or lozenges), also official, each 
consist of ammonium chloride, 0.1 gram 
{lyi grains); extract of glycyrrhiza, 
0.2 gram (3 grains) ; tragacanth, 0.02 
gram (% grain) ; sugar, 0.4 gram (6 
grains), with syrup of Tolu, q. s. 

MODES OF ADMINISTRA¬ 
TION. —Ammonium chloride is best 
given in solution or in the form of loz¬ 
enges. Licorice is decidedly the most 
advantageous agent for disguising its 
unpleasant salty taste. The mistura 
ammonii chloridi of the National For¬ 
mulary, e.g., contains 23/2 parts each of 
the salt and of pure extract of licorice 
in 100 parts of water. Similarly, the 
mistura glycyrrhiscc composita (brown 
mixture) of the U. S. P. is often used 
as a vehicle for ammonium chloride. 
In affections of the lower respiratory 
passages inhalations of freshly formed 
ammonium chloride vapors are also fre¬ 
quently utilized. 

1- 


INCOMPATIBLES. —Ammonium 
chloride is incompatible with alkaline 
compounds or carbonates of the 
stronger alkali metals,—sodium and 
potassium,—or of the metals of the al¬ 
kaline earths,—calcium, strontium, ba¬ 
rium ; the more strongly basic metals in 
these compounds tend to displace the 
ammonium from its chloride. If an 
ammonium chloride solution to which 
sodium or potassium hydroxide has 
been added is heated, gaseous ammo¬ 
nia is evolved. Salts of silver, mercury, 
or lead, in solution, are precipitated as 
insoluble chlorides if combined with 
the chloride of ammonium. 

PHYSIOLOGICAL ACTION.— 
Taken internally, ammonium chloride, 
being less irritating than ammonia or 
ammonium carbonate, causes but little 
reflex irritation of the central nervous 
system through irritation of the gastric 
mucosa. In view of the fact, however, 
that it is destroyed in the blood to a 
much less extent than ammonium car¬ 
bonate and ammonium acetate (which, 
as has already been stated, are largely 
converted to the relatively inert sub¬ 
stance, urea), we would expect ammo¬ 
nium chloride to exhibit the direct stim¬ 
ulating effect of ammonium on the 
nerve-centers more clearly than the 
compounds just mentioned. That this 
is not the case, ammonium chloride be¬ 
ing but slightly a general stimulant, 
tends to support the view, now held by 
many, that the stimulating effects of 
ammonium compounds taken internally 
are exerted through a reflex, rather 
than a direct, action on the centers. 
Nevertheless, if the salt be given intra¬ 
venously, the direct stimulating action 
of ammonium on the spinal cord, the 
respiratory, vasomotor, and other cen¬ 
ters, as well as the heart muscle, be¬ 
comes clearly manifest. It may be pre¬ 
ss 


594 


AMMONIUM (SAJOUS). 


ceded by a period of central nervous 
depression, as was well illustrated in 
the results obtained by Gourinsky in 
experiments on frogs and pigeons. His 
findings were these: In frogs whose 
spinal cord has been divided below the 
medulla oblongata ammonium chloride 
produces, from the first, a marked aug¬ 
mentation of reflex action. In normal 
frogs and pigeons, on the other hand, 
ammonium chloride produces, at first, 
depression of the central nervous sys¬ 
tem, then convulsions; the higher cen¬ 
ters at first exercise an inhibitory influ¬ 
ence on the spinal reflexes. When the 
salt is introduced rapidly, the first stage 
(that of depression) is but slightly 
marked, and soon gives place to the sec¬ 
ond stage (that of irritation, ushered 
in by convulsions). When it is intro¬ 
duced slowly the depression is well 
marked and lasts a long time. In frogs 
and pigeons deprived of the cerebral 
hemispheres only, whatever be the 
method of introducing the salt, convul¬ 
sions are not preceded by depression, 
but the latter is sometimes replaced by 
irritability. All the facts, according to 
Gourinsky, can be explained only by 
the reciprocal action of the nervous 
centers on each other, modified by the 
ammonium chloride. It should be men¬ 
tioned, in this connection, that, in the 
frog, ammonium chloride has a ten¬ 
dency to paralyze the motor nerve-ter¬ 
minals in the muscles; in mammals, 
however, this effect is hardly noticeable, 
even with large doses. 

The most important action of ammo¬ 
nium chloride is that on the secretions 
of the respiratory passages, stomach, 
and mucous membranes in general, 
which are increased and rendered more 
fluid by it. The several ways in which 
this effect may be produced have been 
set forth under ammonium carbonate 


{q.v.). The fact that some of the salt 
is eliminated by the mucous membranes 
suggests that the direct action of the 
drug on the gland-cells must play an 
important role in the effect produced. 
Its elimination with the sweat and urine 
also causes it to be mildly diaphoretic 
and diuretic, as well as expectorant. 

Ammonium chloride has been found 
to produce an increase in all the solids 
of the urine, except in uric acid. 

When given continuously for some 
time, it is believed to cause pathological 
alterations in the blood, which may 
eventuate in general prostration, to¬ 
gether with hemorrhage under the skin, 
from the mucous membranes, and hem¬ 
aturia. 

Externally, ammonium chloride, in 
strong solutions, acts as an irritant. 

THERAPEUTICS.—As a Stimu¬ 
lant to Mucous Membranes .—In Dis¬ 
orders of the Respiratory Tract. —Am¬ 
monium chloride has long been consid¬ 
ered an effective remedy in almost 
every disorder of the respiratory tract. 
More recently the carbonate has re¬ 
placed it in the treatment of pulmonary 
disorders, but the chloride is still widely 
used in chronic bronchitis and acute 
bronchitis after the initial stage of the 
bronchial inflammation has passed that 
of marked congestion and dryness. In 
whooping-cough, also, ammonium chlo¬ 
ride has given fairly good results. The 
drug acts, at least in part, directly on 
the gland-cells of the mucous mem¬ 
branes, with the secretions of which it 
is eliminated into the bronchi. The cells 
are stimulated by virtue of its “salt 
action,’’ the result being a less tenacious 
and more watery secretion of mucus, 
which is more readily evacuated. Fre¬ 
quently the drug is given in combina¬ 
tion with other stimulating expectorant 
remedies. In the terminal stage of 


AMMONIUM (SAJOUS). 


595 


acute coryza and in subacute or chronic 
forms of pharyngitis and laryngitis, the 
beneficial effects of ammonium chloride 
on the mucous membranes are also util¬ 
ized with advantage. 

In pneumonia, ammonium chloride 
has been given in 10-grain (0.6 gram) 
doses every two hours, in the hope of 
in some way favorably modifying the 
inflammatory process in the lung, but 
the results obtained have not been strik¬ 
ing (Brunton). 

Fumes of nascent ammonium chlo¬ 
ride, generated by the action of hydro¬ 
chloric acid on ammonia, are frequently 
administered by inhalation in respira¬ 
tory disorders, and have proven quite 
effective in mild chronic affections of 
the mucous membranes, including bron¬ 
chitis, pharyngitis, laryngitis, etc. 

It is a constituent of the official mis- 
tura glycyrrlmce composita (U. S. P.), 
of mistura ammonii chloridi (N. F.). 

The value of ammonium chloride 
troches, or lozenges, for local stimula¬ 
tion in pharyngeal disorders is well 
known. They serve the double pur¬ 
pose of increasing local lubrication by 
exciting the glandular acini and of 
gently stimulating the hepatic functions 
after the salt has been absorbed. The 
official ammonium chloride lozenge has 
already been referred to; 1 to 6 or more 
of these lozenges may be taken daily. 

Ammonium chloride solution has also 
been used in throat affections in the 
form of a spray. 

In Aural Disorders.—The use of 
chloride of ammonium vapor in affec¬ 
tions of the middle ear has been 
prompted by its effectiveness in catar¬ 
rhal affections of the nasal mucous 
membrane. 

In Gastric Catarrh.—That ammo¬ 
nium chloride is of value in catarrhal 
disorders of the stomach, especially in 


children, is indicated by the frequency 
with which it is still resorted to. Pre¬ 
sumably, its chief action is to loosen the 
mucous secretions. It may be given in 
solution or in pills; if in the latter form 
a half-tumblerful of pure water should 
be taken simultaneously to prevent un¬ 
due irritation of the gastric mucosa by 
the salt. Instead of water, milk may 
be used. 

In Cystitis.—In catarrhal cystitis 
ammonium chloride sometimes proves 
very effective. Ten grains (0.6 gram) 
every four hours on the first day, in a 
tumblerful of water, and 5 grains (0.3 
gram) on the second day and there¬ 
after soon cause the local distress greatly 
to diminish. 

As a Stimulant to the Liver.—In all 
conditions associated with torpidity 
of the liver, whether this be due to a 
subacute hepatitis or to general as¬ 
thenia, ammonia chloride, in doses 
of 20 grains (1.3 grams) three times 
a day, has been found of great value. 

In Alcoholism.—In alcoholic intox¬ 
ication ammonium chloride has been 
said to act as effectively as ammonia. 
Thirty grains (2.0 grams), repeated in 
half an hour, were found to bring the 
sufferer to his normal condition, in 
so far as the mental aberration was con¬ 
cerned. If emesis or lavage had been 
resorted to before the administration of 
the salt, the action of the latter was 
greatly prolonged. 

In Neuralgia and Migraine.—Am¬ 
monium has been found frequently to 
afford considerable relief in these dis¬ 
orders, especially if given with tincture 
of aconite. Twenty grains (1.3 grams) 
of the ammonium salt with 2 minims 
(0.12 c.c.)of the tincture, repeated twice 
after the first dose, at intervals of half 
an hour, usually procured marked dimi¬ 
nution of the suffering. 


596 


AMNESIA. 


External Uses.—In superficial in¬ 
flammatory swellings, e.g., buboes, 
mammary abscesses, testicular inflam¬ 
mations, etc., ammonium chloride 
solutions have been applied locally 
with benefit. 

In vaginitis a solution of 3 drams 
(12.0 grams) of ammonium chloride in 
1 pint (475 c.c.) of water can be used 
as an injection or applied on a tampon 
with benefit (Butler). 

A saturated solution of the salt may 
be used with advantage in bruises, to 
reduce swelling and diminish discolor¬ 
ation. The antiseptic qualities of am¬ 
monium chloride in the treatment of 
wounds have been emphasized by II. 
C. Wyman, who obtained good re¬ 
sults, especially in contused wounds, 
from the use of gauze steeped in a 
solution of 1 ounce of the salt in half 
a pint of water. The circulation of 
blood in the injured parts also ap¬ 
peared to be improved by it. 

In senile gangrene a good therapeu¬ 
tic measure is to place the foot in a 
solution of 8 ounces (250 grams) of 
ammonium chloride to 1 gallon (3800 
c.c.) of water (Butler). It increases 
the alkalinity of the blood and thereby 
its osmotic properties, and facilitates 
its circulation. 

C. E. DE M. Sajous 

AND 

L. T. DE M. Sajous, 

Philadelphia. 

AMMONIUM ICHTHYOL 

GROUP. See ICHTHYOL. 

AMNESIA ,—Loss of memory, in¬ 
cludes failures of memory of various 
kinds, both temporary and permanent, or 
presenting special characteristics, as in 
the amnesic aphasias. It applies also to a 
loss of the power to recall facts of every 
kind, covering a definite period, or the 
entire life of the subject. In a case fol¬ 
lowing prolonged alcoholic stupor re¬ 


ported by A. C. Buckley (Jour, of Abnor¬ 
mal Psych., Feb.-Mar., 1912), there was a 
loss of recollection of all events of the 
life of the individual—he remembered 
nothing up to a definite point. Neverthe¬ 
less, he possessed a remarkable degree of 
tenacity of memory for all events which 
followed his comparatively abrupt psychic 
awakening. This was shown by his abil¬ 
ity to recall and retain all recent events 
when once they were brought to his at¬ 
tention. The re-education process was for 
him a laborious one, covering a period of 
many months, and to those who had the 
opportunity to observe him, it was most 
interesting. 

S. P. Goodhart (Jour. Amer. Med. 
Assoc., Dec. 27, 1913) observed 2 cases of 
temporary amnesia, 1 from the excessive 
use of tobacco, the other a result of 
malarial infection. The first patient was a 
prominent lawyer and teacher, an habitual 
user of strong tobacco, who had indulged 
in unusual excess on account of recent 
mental and emotional stress. The amnesia 
appeared suddenly with a dazed condition 
for a half hour, followed by 3 weeks of 
nearly complete forgetfulness of past and 
current events, but apparently without any 
mental symptoms other than those de¬ 
pendent on the amnesia. Then it gradu¬ 
ally began to disappear, but the complete 
rehabilitation was as sudden as the onset, 
and seemed to take up the normal mental 
activity at the point where it had been 
interrupted. Withdrawal of tobacco, rest 
and nutritional care were all the treat¬ 
ment used. This was several years ago; 
since then slight amnesic attacks have 
followed excessive use of tobacco and 
have been relieved by similar treatment. 
The second patient was a female teacher, 
aged 27, whose mother suffered from 
epilepsy and who was herself somewhat 
high-strung and nervous. The attack, in 
this case, was sudden, after intense emo¬ 
tional strain and fatigue, and was imme¬ 
diately preceded by severe headache. The 
amnesia was complete for the events of 
the previous 48 hours, but less so for 
events more remote. Malarial symptoms 
appeared two days later, and the case was 
a typical tertian with finding of the plas- 
modium. The amnesia continued a pro¬ 
longed period after malarial symptoms 


AMYLENE HYDRATE. 


597 


ceased, and there is yet only partial 
restoration of past recollections. 

Attempts at cure of amnesia by means 
of free association and hypnosis were 
made by Rorschach (Med. Rec., from Cor- 
respondenzbl. f. Schweizer Aerzte, July 
14, 1917). A soldier sent home on fur¬ 
lough did not return on time. Investiga¬ 
tion led to his discovery in a beer cellar 
in a state of mental confusion and am¬ 
nesia. Remoyed to the hospital he was 
able to remember up to a certain hour on 
the first day of his furlough when appar¬ 
ently he had met with an accident. He 
was able to give a good history of him¬ 
self and family, and had never before been 
in a twilight state although there may 
have been an unmotivated tendency in 
boyhood to wander. He had always been 
alcohol-intolerant and 2 glasses of beer 
were enough to rob him of self control. 
Once he had had an unmotivated attack 
of weeping. His record as a soldier was 
good save on one occasion, when he had 
failed to get up in the morning. When 
interned he was pale, complained of head- 
iche, was alternately euphoric and anx¬ 
ious, and showed numerous peculiarities 
of behavior. He was first tested with 
ordinary association (Jung-Riklin) which 
was at least 93 per cent, internal. Great 
uniformity was shown, and the total re¬ 
sults pointed strongly to epileptic asso¬ 
ciation. Free association tests per se could 
throw no light on the amnesia and the 
patient was then hypnotized. Under hyp¬ 
nosis certain things were remembered but 
there were many gaps and posthypnotic 
suggestion failed completely. It seemed 
beyond doubt, by the character of the 
recollections, that during the twilight state 
patient had been in a delirium which by 

its content suggested an organic brain 

c 

disease. 

AMPUTATIONS AND RE¬ 
SECTIONS. See Resections, Am¬ 
putations, Etc. 

AMYL NITRITE. See Nitrites. 

AMYLENE CHLORAL. See 

Dormiol. 

AMYLENE HYDRATE. — This 

substance is chemically tertiary amyl 


alcohol or dimethylethylcarbinol [(CH 3 ) 2 - 
C(C 2 Hr,)OH]. It occurs as a colorless, 
volatile, oily liquid, having an unpleasant 
ethereal odor and a burning, camphor-like 
taste. It is produced by the interaction of 
amylene, water, and sulphuric acid. Its 
specific gravity at ordinary temperatures 
is 0.820, and its boiling point is 99°-103° C. 
It is soluble in 8 parts of water and mixes 
freely with alcohol, ether, chloroform, 
and glycerin. It should be kept in well- 
stoppered bottles. 

DOSE AND MODES OF ADMINIS¬ 
TRATION.—The dose of amylene hydrate 
taken by the mouth, for adults, is 30 to 
90 minims (2 to 6 c.c.). If it is to be ad¬ 
ministered by the rectum, slightly larger 
amounts are required. 

The disagreeable taste of amylene hy¬ 
drate may be avoided by enclosing it in 
capsules (15 minims in each; 3 capsules 
at a dose) or by administering it in fla¬ 
vored solutions such as the following:— 

R Amylene hydrate. 1 dr. (4 Gm.). 

Water .2 oz. (60 c.c.). 

Orange-flozver 

zvater .2 oz. (60 c.c.). 

Syrup of hitter 

orange . 1 oz. (30 c.c.). 

M. 

Of this one-half may be taken at night. 

Where an analgesic effect is required in 
addition to the hypnotic influence, mor¬ 
phine may be combined with amylene hy¬ 
drate, as in the following formula, recom¬ 
mended by Fisher:— 

IJ Amylene hydrate. 1]^ drs. (6 Gm.). 

Morphine hydro¬ 
chloride . /4 gr- (0.015 Gm.). 

Distilled zvater .. 3 oz. (90 c.c.). 

Extract of lic¬ 
orice . 2k^ drs. (10 Gm.). 

M. Sig.: To be taken in two doses two 
hours apart. 

Amylene hydrate may also be given in 
wine, beer, or brandy. A mixture of wine 
and syrup of licorice forms an especially 
good vehicle. 

It cannot be employed subcutaneously, 
owing to the severe irritation and pain 
produced. 

PHYSIOLOGICAL ACTION.—Amy¬ 
lene hydrate, like alcohol, causes a primary 
apparent excitement followed by depres- 







598 


AMYLENE HYDRATE. 


sion and ultimate paralysis of the nerve- 
centers. The brain, cord, and medulla are 
stimulated and depressed in succession, 
• the secondary results being sleep, aboli¬ 
tion of reflex activity, and respiratory 
arrest. In the lower animals large doses 
have been found to induce cardiac depres¬ 
sion and a pronounced fall in the body 
1 temperature. The latter effect has been 
credited to a direct action of the thermic 
centers. In man, however, amylene hy¬ 
drate in moderate doses does not influence 
the temperature to any degree, even in 
fever. Neither does it depress to any 
marked extent, except in grossly excessive 
doses, the cardiovascular functions and 
respiration,—a feature in which it is supe¬ 
rior to chloral hydrate. Amylene hydrate 
has but little influence on general metab¬ 
olism. The elimination of urea is said to 
be more or less diminished after its in¬ 
ternal use. 

Locally, it is somewhat of an irritant. 
Upon subcutaneous injection tissue necro¬ 
sis and abscess formation may result. 

UNTOWARD EFFECTS; POISON¬ 
ING. —According to Scharschmidt, some 
patients perspire freely at the beginning 
of the effects of amylene hydrate. Occa¬ 
sionally excitement similar to that pro¬ 
duced by alcohol or slight degree of stupor 
are produced by it. Headache and dizzi¬ 
ness in a few instances follow its use. 

Four cases of poisoning from overdoses 
were witnessed by Dietz. The symptoms 
consisted of deep sleep, from which the 
patients could not be aroused, complete 
motor paralysis, and loss of sensibility, 
including both touch and pain. The pupils 
were dilated, and reacted but slowly to 
light; the corneal reflex was abolished. 
Respiration was slow, superficial, and 
irregular; the pulse small, soft, and in¬ 
frequent, and the temperature, in two in¬ 
stances, lowered to 95° F. Artificial res¬ 
piration was required in one case. During 
recovery mental confusion and motor in¬ 
co-ordination were conspicuous. In each 
case the overdose had been taken through 
neglect to shake the bottle in which the 
drug was mixed with syrup. Dietz advises 
that to avoid such accidents the drug be 
administered in capsules. 

No instances of amylene-hydrate habit 
or cachexia have been observed (Flint). 


THERAPEUTIC USES.— Amylene hy¬ 
drate was introduced in medicine as a 
hypnotic by von Mehring, and has since 
held a favorable position as such, though, 
as Cushny states, it “has not received so 
wide a trial as it would seem to merit.” 
Its effects rather closely resemble those 
of paraldehyde, but it leaves no bad taste 
in the mouth or disagreeable odor on the 
breath, such as are noticed with paralde¬ 
hyde after the patient has awakened. In 
hypnotic power it is stronger than paralde¬ 
hyde, but weaker than chloral hydrate. 
Likewise it is believed to exert a greater 
depressing influence on the heart than 
paraldehyde,—though less than chloral 
hydrate. Kirby and Griffith recommended 
that this drug be always used in heart 
disease in place of chloral. They also 
stated that in their experience amylene 
hydrate did not lose its efficiency upon 
continued use,—though given during three 
months in some cases,—and that the deep 
and refreshing sleep produced by the 
drug was praised by patients oftener than 
in the case of any other,hypnotic. 

Amylene hydrate differs in its action 
from chloral in that it does not increase 
nitrogenous wastes. According to Peiser 
the quantity of nitrogen eliminated by the 
urine after amylene hydrate is, in fact, 
lessened. This author therefore prefers 
the drug to chloral whenever the hypnotic 
effects are to be continued for a long time 
and in all affections associated with an 
exaggerated decomposition of albumins,— 
in fever, in anemia, pulmonary tuber¬ 
culosis, and diabetes. 

Sleep follows the ingestion of amylene 
hydrate much more promptly than after 
sulphonal, and it does not tend, as does 
the latter, to produce drowsiness and 
giddiness on the following day. 

On the whole, amylene hydrate is, ac¬ 
cording to Kirby and Griffith, a reliable 
hypnotic if given in sufficient dose, though 
it is somewhat less certain in effect than 
chloral or morphine. When given by the 
rectum (in an enema with gum arabic and 
water), amylene hydrate brings on sleep 
in fifteen to forty-five minutes, or even 
sooner, though occasionally it fails entirely 
to do so. 

Amylene hydrate acts satisfactorily in 
insomnia associated with nervousness, ex- 


AMYLOFORM. 


599 


cessive mental strain, fevers, and anemia. 
Its usefulness in cardiac states has already 
been referred to. 

In gastric disorders its oral use is apt 
to result in local irritation and nausea; in 
such cases it should be administered by the 
rectum. It is less irritating to the rectal 
mucous membrane than chloral hydrate. 

In the insomnia of mental diseases, amy- 
lene hydrate has seen extensive service. 
In a series of 149 cases Lehmann obtained 
good results with it. In mania large doses 
were required. Cases of paralysis of the 
insane were benefited, but in the insomnia 
of melancholia it was less effective. It 
proved to be more efficacious and less un¬ 
pleasant than paraldehyde. 

Avellis found amylene hydrate generally 
effective in alcoholic delirium. 

In a case of opium addiction in which 
chloral, bromides, paraldehyde and hyos- 
cine, singly or variously combined, had 
given indifferent results, amylene hydrate 
produced sleep lasting through the night 
with but little or no intermission (Kirby 
and Griffith). Like results have been 
noted by other observers. 

In pulmonary disorders, G. Mayer found 
amylene hydrate not only to produce 
sleep, but apparently to exert a decided 
sedative influence on the cough. In tuber¬ 
culosis it sometimes proved useful in this 
respect after morphia had had but little 
effect. When there was pain or very 
troublesome cough, however, it was not 
uniformly successful. S. 

AMYLOFORM.— Amyl of orm is a 
condensation product of formaldehyde and 
starch, first prepared by Classen, of 
Aachen, in 1896. It occurs in the form of 
very fine, white, odorless, and tasteless 
powder, which is insoluble in ordinary 
solvents. It remains undecomposed at a 
temperature of 180° C. 

PHYSIOLOGICAL ACTION.— Amylo- 
form is but slightly irritating. It is 
strongly antiseptic, disinfectant, deodor¬ 
ant, and absorbent, and is said to have all 
the advantages of iodoform without pos¬ 
sessing its disagreeable odor. When ap¬ 
plied to living tissue it is broken up into 
its two components,—formaldehyde and 
starch,—as shown by the fact that formal¬ 
dehyde can be detected in the purulent 


discharge from suppurating wounds to 
which it has been applied (Classen). No 
symptoms of general intoxication are pro¬ 
duced by the application of amyloform, 
though temporary smarting sensation 
locally is sometimes complained of. The 
secretions from open surfaces are rapidly 
checked by it. 

THERAPEUTIC USES.— The drug is 
employed either as a dusting powder or in 
an ointment. Its uses are much the same 
as those of iodoform. Bongartz employed 
it with success in cases of deep wounds 
with bone suppuration and in varicose 
ulcers of the leg. Heddaeus laid stress on 
its rapid disinfecting action on tuberculous 
lesions. Its most important use, accord¬ 
ing to this author, is in the treatment of 
superficial suppurative affections. Lou- 
gard and Beauchamp used the drug in 
numerous cases of phlegmon, abscess, fu¬ 
runcle, etc., including gynecologic affec¬ 
tions. Krabbel, who tested it both bac- 
teriologically and clinically, came to the 
conclusion that amyloform was in no way 
inferior to iodoform as an antiseptic, C. 
L. Schleich, however, contends that it 

holds free starch, which smears up the 
wound and greatly hinders favorable 
action of the formaldehyde it contains. 

Contrary to iodoform, amyloform 
can be sterilized in dry or moist heat 
without being decomposed. Because 
of this property, amyloform gauze 

affords some assurances of asepsis 
which are not found in the other 
antiseptic gauzes. An emulsion for 
preparing amyloform gauze is:— 

B Amyloform.to 2]/2 drs. (5-10 Gm.). 

Glycerin ...2^4 drs. (10 Gm.). 

Alcohol ....UlA drs. (50 Gm.). 

Ether .10 drs. (40 Gm.). 

01. ricini .. mins. (0.5 Gm.). 

The indications for amyloform are 
the same as for iodoform. (Presse 
med,. Sept. 15, 1900.) 

Good results obtained with amylo¬ 
form, The writers prefer it to the 
latter drugs in incised abscesses, 
ulcers, wounds, burns, and purulent 
otorrhea. Besides being harmless 
and free from any compromising 
odor, it remarkably hastens cicatriza¬ 
tion. Cipriani (Monats. f, prakt. Der- 
mat., Oct. 15, 1900). 


600 


AMYL VALERATE. 


ANALGEN. 


Amyloform used in fresh and neg¬ 
lected wounds, ulcers of the leg, 
excoriations, intertrigo, felons, car¬ 
buncles, osteomyelitis, tuberculous 
ulcerations, etc. The pure powder 
usually employed. This occasions 
slight burning in sensitive patients, 
which, however, disappears soon. 
The chief features of its action are 
that it hastens granulation, diminishes 
secretion, and is, as a rule, non-irri¬ 
tating. Its freedom from odor and 
toxic effect is also noteworthy. A. 
Gerlach (Therap. Monats., Bd. xvi, 
Nu. 10, 1902). S. 

AMYL VALERATE (Amyl Vale- 

rianate).—This is the isoamyl ester of iso¬ 
valeric acid, and is a reaction product of 
amyl alcohol with sulphur and valeric 
acids. It represents the odoriferous prin¬ 
ciple of the apple, and occurs as a color¬ 
less liquid of specific gravity 0.858 and 
boiling point 190° C. (374° F.). It is in¬ 
soluble in water, but dissolves in alcohol, 
ether, and chloroform. When in dilute 
solution, its ethereal apple-like odor is 
plainly evident. 

PHYSIOLOGICAL ACTION.— Cider 
has long been believed by the laity to 
exert some favorable effect on calculous 
formations, and this seems to be borne 
out by the fact that amyl valerate actually 
does possess a certain solvent power with 
reference to cholesterin. Fifteen grains of 
cholesterin are dissolved by 70 grains of 
amyl valerate at 99° F., and by 46 grains 
at 104° F. Where the amount of choles¬ 
terin present exceeds the dissolving power 
of the valerate, it is, nevertheless, greatly 
softened,—to the consistency of gelatin. 

The ingestion of amyl valerate induces 
primary general excitation and accelera¬ 
tion of the pulse, followed by somnolence 
(Pouchet). In addition to modifying or 
dissolving cholesterin, it tends to relax 
the bile-duct when in spasm. 

THERAPEUTIC USES.— Amyl vale¬ 
rate was introduced by Blanc as an anti- 
spasmodic for use in hepatic and renal 
colic, and as a solvent for cholesterin cal¬ 
culi. It is said in hepatic colic not only to 
overcome the acute attack, but to prevent 
recurrences. No solvent effect on renal 
calculi is, however, claimed for it. The 


drug is administered in capsules; a cap¬ 
sule containing 2 to 6 minims (0.12 to 
0.4 c.c.) may be given every half-hour, or 
one containing a somewhat larger amount, 
three times daily. The use of amyl vale¬ 
rate should be continued for some days 
after the acute disturbance has subsided. 

Amyl valerate has also been employed 
in muscular rheumatism, in dysmenorrhea, 
and as a sedative in hysteria. S. 

ANALGEN (quinalgen; labordin) is, 
chemically, the benzoylamido derivative 
of orthoethoxyquinoline [C 9 H 5 .(OC 2 H 5 )- 
N.H.(C0.C6H5)N]. It bears the same 
relation to quinoline as acetphenetidin 
does to benzene, with the exception that 
in analgen the benzoyl group takes the 
place of the acetyl in acetphenetidin. 
With the exception of thallin and ther- 
mifugin, it is the only member of the 
quinoline group of coal-tar analgesics or 
antipyretics which is still occasionally pre¬ 
scribed. It occurs in the form of color¬ 
less, tasteless crystals, soluble in hot alco¬ 
hol and in acidulated water, slightly so in 
cold alcohol, and insoluble in pure water. 

PHYSIOLOGICAL ACTION.— Anal¬ 
gen possesses the same antipyretic and 
analgesic properties as acetphenetidin, and 
its mode of action is closely similar (v. 
Acetphenetidin). With large doses, the 
same circulatory depressant tendency is 
present as with other coal-tar drugs. 
Analgen is more toxic than acetphenet¬ 
idin, though less so than acetanilide. It 
is the least dangerous of the quinoline 
derivatives. 

Analgen given experimentally to mam¬ 
mals induces motor depression and dimin¬ 
ished reflex response, followed, with toxic 
doses, by cyanosis and convulsive move¬ 
ments. 

The effects of analgen, when it is in¬ 
gested, begin only after the benzoyl group 
in it has been set free by the gastric juice. 
Its action is, therefore, somewhat slower 
in appearing than is the case with ace¬ 
tanilide and antipyrin, and is to a certain 
extent inconstant. 

A special feature of the action of anal¬ 
gen is that in large doses or upon con¬ 
tinued use it produces a reddish discolora¬ 
tion of the urine. This coloration, when 
slight, is rendered more marked by the 


ANAPHYLAXIS. 


601 


addition of acetic acid (1 to 10). Accord¬ 
ing to some, the coloration is due merely 
to the presence of decomposition products 
of analgen in the urine; according to 
Moncorvo, on the other hand, it is due to 
blood-coloring matter. 

THERAPEUTIC USES.—The average 
dose of analgen for adults is lYz grains 
(0.5 Gm.). According to Goliner, the 
maximum single dose is ISyz grains (1.0 
Gm.) and the maximum daily amount 45 
grains (3 Gm.). The drug has been used 
chiefly as an antineuralgic and antipyretic. 
Of late its use has, however, greatly 
diminished, the official drugs acetanilide, 
antipyrin, and acetphenetidin meeting with 
greater favor. Besides, the use of any 
antip 3 ^retic has justly lost favor. 

Scholkow, Foy, Spiegelberg, and Maas 
found analgen effective in a large number 
of cases of neuralgia- According to Foy, 
who used it in 200 patients, the full dose 
of 15 grains (1.0 Gm.) was necessary to 
produce relief. In the pains of tabes, zona, 
and hysteria, the results were less brilliant, 
but in acute articular rheumatism and 
muscular rheumatism distinct benefit was 
noted in many instances. According to 
Maas, patients suffering from pulmonary 
tuberculosis experience “a peculiar feel¬ 
ing of wellbeing” from its use. Moncorvo 
used analgen in 59 children, 33 of them 
presenting various malarial manifestations, 
with satisfactory results. It was readily 
taken, because tasteless, and in no instance 
exerted any unfavorable action on the cir¬ 
culation or respiration. The urine became 
colored a deep yellow or red, but albumin 
and sugar were never detected. It acted 
satisfactorily as a sedative in chorea, 
hysteria, and partial epilepsy and was 
found useful to relieve pain of various 
kinds, including that of Pott’s disease and 
hip-joint tuberculosis. 

Occasional instances of untoward sec¬ 
ondary effects are recorded by Scholkow 
and Spiegelberg, including headache, tin¬ 
nitus, nausea, diarrhea, and tremor. Pa¬ 
tients taking analgen should be informed 
of the red discoloration likely to appear 
in the urine, lest they be unduly frightened 
thereby. 

ANAPHYLAXIS ,—This term was 
introduced by Richet of Paris in 1902 to 


designate a peculiar power possessed by 
certain poisons of increasing the sensitive¬ 
ness of an organism to their toxic action. 
Von Pirquet, on the plea that it implied 
absence of systemic defense, whereas the 
reaction was one occurring beside, though 
linked • to, immunity, termed it allergy, 
meaning another or additional reaction. 
Until the nature of the process is better 
known, however, it is preferable to employ 
Richet’s original term, since what it does 
mean is a condition of hypersensitiveness 
which may ultimately prove to be but a 
phase of immunity. 

Symptoms.—Diphtheria and tetanus anti¬ 
toxin and other sera, antityphoid, anti- 
dysenteric, antiplague streptococcic, etc., 
give rise, as is well known, to untoward 
effects which formerly were attributed to 
“idiosyncrasy,” “supersensitiveness,” etc. 
The various phenomena developed have 
been called serum disease by von Pirquet, 
though the term applies specifically to one 
syndrome following occasionally injec¬ 
tions of horse serum, the proteins of 
which is the harmful factor. While, for 
example the use of diphtheria antitoxin 
is, as a rule, devoid of danger, such hyper¬ 
sensitive persons, often owing to previous 
injections, the presence of asthma, and 
sometimes without apparent cause, be¬ 
come seriously ill—fatally so in some rare 
instances. 

The interval between an injection and 
the appearance of the morbid symptoms 
may be but a few minutes, several days, 
or even weeks. As a rule, however, it 
occurs before the eleventh day. A second 
injection is thought to be safe, where the 
first injection has given rise to no un¬ 
toward effect, within six days, but this 
rule cannot be accepted as infallible. The 
attack may consist only in more or less 
redness of the face or severe urticarial 
eruption over the face and body, with in¬ 
tense pruritus; but, as a rule, it is far 
more severe, there being fever, with leu- 
cocytosis, usually eosinophilic, swelling of 
the lymphatic glands, edema, pains in the 
joints and in the back, albuminuria, a 
marked rise of blood-pressure, followed 
in severe cases by a decline of pressure— 
usually a precursor of death. 

The suddenness with which lethal symp¬ 
toms appear is sometimes appalling. 


602 


ANAPHYLAXIS. 


Thus some years ago E. L. Boone re¬ 
ferred to “an apparently very strong and 
extremely well developed boy of 10 years 
who was given 4000 units of diphtheria 
antitoxin belov/ the scapula. This was 
almost immediately followed by a loud cry 
of distress, strangling and choking cough, 
dyspnea, cyanosis, pallor about the lips, 
frothing at the mouth, a convulsion and 
death—all within 5 or 6 minutes.” In an¬ 
other case, recorded by W. W. Hendricks, 
but 1000 units had been injected as a 
prophylactic, also in the scapular region, 
the child, a boy of 7 years, being perfectly 
well. “In 5 minutes,” states the author, 
“the child was brought back unconscious 
. The skin was livid, the lips and 
nails blue, the lips and eyes swollen, the 
eyes half open, the pupils equally dilated, 
and the conjunctivas injected. The jaws 
were firmly closed and a frothy mucous 
was found coming from the mouth and 
nose, the tongue was found swollen, and 
protruded when the jaws were forced 
open.” These cases illustrate the fact that 
no evident disease may be present to warn 
the physician, and, moreover, that the 
smallness of the dose of diphtheria anti¬ 
toxin may not prevent morbid effects. 

Case of acute anaphylaxis in a 
young man following the administra¬ 
tion of 10,000 units of antitoxin for 
diphtheria. In 5 minutes symptoms 
of respiratory distress began to de¬ 
velop and patient became very rest¬ 
less and apprehensive. The respira¬ 
tory symptoms became progressively 
worse and patient more and more 
cyanotic until voluntary respiration 
ceased at 12.55 a.m. 10 minutes after 
the antitoxin was administered. Ar¬ 
tificial respiration, oxygen and stimu¬ 
lants had not the slightest effect. 
The heart beat weakened and finally 
stopped at 1.10 a.m. It was subse¬ 
quently ascertained that since he was 
a child cats caused attacks of sneez¬ 
ing whenever they came in his vicin¬ 
ity. He also was troubled with hay 
fever every fall until last fall, when 
he was on the Lakes and escaped his 
usual autumn attack. C. W. Carr 
(U. S. Naval Med. Bull,, July, 1918). 

As regards the development of un¬ 
toward phenomena long after the initial 


treatment, Gillespie (Austral. Med. Gaz., 
June 22, 1912) records a case in which 
very serious symptoms were caused by 
the injection of antidiphtheritic serum 
about 18 months after a previous injec¬ 
tion. The patient collapsed 15 minutes 
after the injection, became unconscious, 
vomited 5 times in 6 hours, had very 
shallow respiration, 35 to the minute, a 
pulse of very poor tension, 120, regular, 
and a temperature of 101.2° F. (38.4° C.). 
He began to recover consciousness at the 
end of 4 hours of active treatment, anc 
made a good recovery, except that on the 
sixth day an urticaria developed. 

Such cases are extremely rare, however, 
so rare in fact, that some observers of 
vast experience have never witnessed it. 
This fact should be borne in mind, for 
Guaita (Semana Medica, Aug. 21, 1913) 
relates a number of instances in which the 
parents refused to permit the use of anti¬ 
toxin in diphtheria for fear of anaphylaxis, 
as the child had been injected with anti¬ 
toxin on some previous occasion. In all 
his experience, and in that of Penna at 
the contagious disease hospital, Cabrera’s 
at the diphtheria pavilion in the children’s 
hospital and of others he cites, no in¬ 
stance of anaphylaxis has been encoun¬ 
tered, although some of the patients had 
received several injections of antitoxin. 
He declares that this dread of anaphylaxis 
is irrational and extremely dangerous. 

Cutaneous eruptions, however, are rela¬ 
tively common. Thus, Sturtevant (Ar¬ 
chives of Int. Med., Jan., 1916) in a series 
of 500 cases found that out of 422 which 
had received but one injection, 20 per cent, 
had an urticarial or erythematous rash. 
The reaction occurred as a rule between 
the fifth and ninth day, though occasion¬ 
ally as early as the first and late as the 
nineteenth day, this being in no way in¬ 
fluenced by the dose. Nausea and vomit¬ 
ing occurred in 9 per cent, of the reacting 
cases, and was more likely to occur and 
to be severe and prolonged if the dose of 
serum was increased. Albuminuria and 
edema appeared occasionally, and joint 
symptoms, sometimes severe, in about 14 
per cent, of the reacting cases. When a 
given amount of serum was administered 
in 2 or more doses, it seemed ^s likely to 
produce a reaction as a single injection. 


ANAPHYLAXIS 


603 


The large proportion of untoward ef¬ 
fects in Sturtevant’s cases does not seem 
to attend the use of foreign sera. This 
is well shown by P'. Cuno’s experience 
(Deut. med. Woch., May 14, 1914) in 3500 
children. Of these, 97 received second 
injections at intervals of from 1 to 114 
months after the first administration; 11 
received both second and third courses of 
injections with intervals of from 1 to 130 
months between the several courses; and 
96 children had repeated doses from 10 to 
63 days after the primary. This makes 
207 in all who had second courses of in¬ 
jections, and of these only 1 showed 
symptoms of anaphylactic response. 

Scarlet fever serum seems also to be 
less benign in its efifects. Thus Nemmser 
(Deut. med. Woch., Apr. 17, 1913) ob¬ 
served no anaphylactic symptoms in 3000 
children at the Petrograd Hospital for In¬ 
fectious Diseases, after a single prophylac¬ 
tic injection. In 1002 recorded cases which 
had received 2 or more injections, how¬ 
ever, serum eruptions were mentioned in 
42 cases, i.c., in less than V 2 of 1 per cent., 
with no serious phenomena. 

In alimentary anaphylaxis we have a 
form caused, as its name indicates, by cer¬ 
tain foods, notably eggs, milk, and mus¬ 
sels. As described by Laroche, C. Richet, 
Jr., and F. Saint-Girons (Paris Med., Apr. 
18, 1914), the symptoms in severe cases 
may appear from 15 seconds to ,45 min¬ 
utes, and usually consist at first of urti¬ 
caria, violent cramps, or vomiting. Diar¬ 
rhea almost always follows, and respira¬ 
tory and nervous disturbances may also 
appear. Mild alimentary anaphylaxis is 
much more frequent, and may occur either 
in adults with previous slight intolerance 
to some single article of food, or in chil¬ 
dren the variety of whose diet is increased 
too suddenly. Thus a child of 3 to 5 years 
may have taken 2 or 3 eggs a day for some 
weeks or months; gradually there appear 
disturbances such as chronic indigestion, 
heavy breath, constipation or diarrhea and 
urticaria, prurigo, or eczema. The urti¬ 
caria sometimes recurs after each meal, at 
other times is practically chronic. At 
times edema of the face, eyelids, or limbs 
appears. Excessive feeding and insuffi¬ 
ciency of the digestive secretions appear 
to favor alimentary anaphylaxis. Al¬ 


though the quantities of food, e.g., of egg 
albumin, required to bring on symptoms 
need be only trifling, the amounts neces¬ 
sary to establish the anaphylactic state are 
usually relatively large, at least 1 or 2 
eggs daily in addition to the ordinary diet. 
Diagnostic features are the suddenness of 
symptoms, almost immediately after in¬ 
gestion, and the fact that symptoms ap¬ 
pear each time an attempt is made to 
accustom the subject to the food in ques¬ 
tion, no matter how small the quantity. 

The writer observed that in cases 
of intolerance of eggs, shellfish, etc., 
the symptoms took the form of cir¬ 
cumscribed transient edema, urticaria, 
migraine, or asthma. In such cases 
a small amount of the harmful food 
taken an hour before the meal, or a 
tablet of 0.4 or 0.5 Gm. (6 or 71/2 
grains) of peptone, gives good re¬ 
sults. The peptone seems to be poly¬ 
valent for most of the articles caus¬ 
ing the anaphylaxis. Some patients 
require the continuous use of the 
peptone, others do better when it is 
given for 3 to 8 days followed by an 
interval of the same length. With this 
simple measure they have succeeded 
in curing the tendency in time in 
many cases. Pagniez and Vallery- 
Radot (Annales de Med., Oct., 1920). 

Anaphylaxis is thought to explain vari¬ 
ous diseases of childhood. Thus Pisek and 
Pease (Boston Med. and Surg. Jour., Jan. 
25, 1912) hold that among these are many 
spasmodic conditions in children which 
have long been attributed to exaggerated 
irregularity of the children’s system. The 
suddenness of their onset and the rapidity 
with which they disappear suggest that 
they belong to the group of anaphylactic 
reactions—laryngeal spasm, tetany, ec¬ 
lampsia, certain forms of asthma, and 
some of the severer types of convulsive 
seizures, for example. 

Among the diseases also attributed to 
anaphylaxis are hay fever. The newer 
literature upon this subject is given under 
Hyperesthetic Rhinitis, in this volume. 

Diagnosis and Pathogenesis.—The symp¬ 
toms of anaphylaxis include, we have seen, 
several pointing to involvement of the 
respiratory, vascular, cutaneous, and gas- 


604 


ANAPHYLAXIS. 


tro-intestinal systems. The dyspnea and 
in severe cases apnea, and the result¬ 
ing cyanosis have been found by Biedl 
and Kraus, Anderson and others, to be 
due to spasmodic contraction of the 
bronchial musculature—the identical caus¬ 
ative feature of bronchial asthma. Where 
asthma exists, therefore, anaphylaxis is 
likely to occur. This symptom may appear 
hot only in serum disease but sometimes 
in alimentary anaphylaxis as well, as 
shown by Talbot (Boston Med. and Surg. 
Jour., p. 708, 1914, and 191, 1916) Schloss 
(Am. Jour, of Dis. of Children, p. 346, 
1916) and others, the vomiting, abdominal 
pain and diarrhea being but eliminatory 
phenomena. 

The peripheral symptoms, cutaneous 
and vascular, are seemingly closely re¬ 
lated, not only mutually, but also with the 
respiratory signs. The toxemia which in 
the lungs produced spasm of the bron¬ 
chial musculature, likewise provokes 
spasm of the vascular muscles; hence the 
angioneurotic edema, of which the swell¬ 
ing of the lips, tongue, buccal mucosa, 
pharynx and esophagus are corresponding 
expressions. A similar constriction of the 
pupillary vessels causes the bilateral dila¬ 
tation of the pupils. Far more dangerous 
in its effects, is the simultaneous contrac¬ 
tion of the cardiac vessels among others 
and ischemia of the myocardium as re¬ 
sult, the blood-pressure being at first 
high, then increasingly low, until prostra¬ 
tion, collapse and death supervene, all in 
rapid succession. The urticaria, urticarial 
wheals, erythema and eczema are also the 
result of vascular spasm, their immediate 
cause being imprisoned wastes—ephem¬ 
eral in some cases, persistent and grave in 
others. 

[This interpretation of the pathogenesis 
of anaphylaxis summarizes personal studies 
of the subject. As we shall see below we 
are dealing from my viewpoint, with a 
vasomotor spasm, due undoubtedly to in¬ 
termediate protein wastes—whether de¬ 
rived from horse serum, ingested foods or 
parenterally introduced proteins. Gay 
and Southard, Auer and Lewis, and others 
several years ago found that the asphyxia 
was due to tetanic contraction of the finer 
bronchioles, with alternating rise and fall 
of the blood-pressure. C. E. de M. S.] 


Various tests have been proposed to 
determine the identity of the protein to 
which a given subject may be sensitive— 
where undetermined foods provoke toxic 
phenomena. 

The simplest of these is the elimination 
test, which consists in placing the patient 
on a bland diet known to produce no un¬ 
toward effects, then adding thereto a sus¬ 
pected article of diet at a time at 3 or 4 
days’ intervals until the characteristic 
morbid effects are noted. 

The cutaneous test is more satisfactory. 
The skin is abraded without drawing 
blood and an aqueous 5 per cent, solution 
of the suspected food or of pure proteins 
is rubbed in as in ordinary vaccination, 
controlling it by means of a 5 per cent, 
lactose in normal saline solution. An 
urticarial wheal with a pink areola ap¬ 
pears in about 10 minutes and persists 
about 30 to 40 minutes. 

The intracutaneous test (not Jw&cutane- 
ous) is still more sensitive, but somewhat 
painful. A small drop of a 2 per cent, 
aqueous solution of pure protein is in¬ 
jected into the skin (not under it, as 
alarming symptoms might result) with a 
very fine needle, the syringe being laid 
almost flat on the arm. The same urti¬ 
carial wheal with an erythematous areola, 
with, perhaps, a small papule, develops in 
about 24 hours provided the reaction is 
positive. 

Etiology and Pathology—All proteins, 
living or dead, contain a poisonous sub¬ 
stance which, under normal conditions, is 
destroyed in the gastro-intestinal canal in 
the course of digestion, during which the 
proteins are converted into the non- 
poisonous amino-acids. When, however, 
proteins, sera, eggs, milk, protozoa, bac¬ 
teria, etc., are introduced otherwise than 
by way of the stomach and enteric canal, 
i.e., parenterally, through the skin, the 
vessels, and perhaps the respiratory 
mucosa, wounds, etc., their toxicity is not 
eliminated, and it evokes, as antigen, a 
defensive reaction. The anaphylactic 
symptoms occur, however, when, after a 
first dose, generally termed the “sensitiz¬ 
ing dose” of any kind of protein, is fol¬ 
lowed sometime later by a second dose— 
the “toxogenic dose.” How are the mor¬ 
bid phenomena described brought about? 


ANAPHYLAXIS. 


Many theories have been vouchsafed, 
but none so far have fully met all the 
phases of the problem. Richet thought 
the first dose caused the formation of 
“toxogenin” which, when the second dose 
was injected combined with the latter to 
form “apotoxin,” the anaphylactic poison. 
While this earliest of the many theories 
proposed, including those of Gay and 
Southard, Besredka, and Vaughan and 
Wheeler, each of which supplied some 
elucidative feature, it formed the basis of 
Friedberger’s second theory, which seems, 
at least, to account for most of the known 
facts. The first dose, he found, formed a 
toxic under the influence of the immune 
body increasingly developed by the animal 
after that dose. While this first poison is 
insufficiently active to awaken morbid 
phenomena, it increases greatly in quan¬ 
tity and virulence when the “toxogenic 
dose” is injected and becomes, together 
with the complement normally contained 
in the blood, the “anaphylatoxin” which 
causes the anaphylactic attack. 

[While this theory best explains the 
formation of the anaphylactic poison, it 
does not explain the manner in which the 
poison produces its effects. This brings 
us back to the personal view that we are 
dealing with an intense spastn of the vascu¬ 
lar, cardiac and bronchial vessels caused 
directly by the anaphylatoxin; upon this 
our therapeutic measures should be con¬ 
centrated.—C. E. DE M. S.] 

The many different procedures 
which have proved useful in prevent¬ 
ing anaphylactic shock either prevent 
flaking of the blood serum or cause 
vasodilation. This indicates that ana¬ 
phylactic shock is due to physical 
changes in the blood serum which 
permit flocculation of the molecules. 
The flakes thus formed obstruct the 
capillary network, and thus induce 
fulminating asphyxia. Prophylaxis 
and treatment call for measures to 
diminish the surface tension of the 
blood serum (saponin, soaps, bile 
salts, anesthetics, hypnotics, lecithin, 
etc.), or to render the serum more 
viscous (sugars, glycerin, acacia, car¬ 
bonates, alkalies, etc.), or to dilate 
the blood-vessels to allow the pas¬ 
sage of the flaked micella (calcium, 


605 

lactate, atropine, etc.). Kopaezewski 
(Annales de Med., Oct., 1920). 

Emphasis laid upon anaphylaxis as 
a sequence of emaciation. In the in¬ 
fant with chronic anaphylaxis the 
emaciation may, of course, be attrib¬ 
uted to gastroenteric indigestion, but 
the failure of digestion and assimila¬ 
tion may itself be explained as a con¬ 
sequence of the anaphylaxis. Pepsin 
and pancreatin are both indicated to 
place the prima; vice in favorable con¬ 
dition. The principal therapeutic re¬ 
source is injection of boiled milk 
subcutaneously to desensitize the 
patient. The use of peptone in urtic¬ 
aria and even for drug anaphylaxis 
has given some surprising results. 
Laroche, Richet, Jr., and Saint-Girons 
(Bull, med., July 10, 1920). 

Prophylaxis.—Various measures have 
been proposed, but, of all, the most satis¬ 
factory, when diphtheria antitoxin is to be 
used, is that advocated by William H. 
Park in 1912 (Med. Record, Nov. 22, 
1913). Experimentally, he found that a 
single does of antitoxin given after infec¬ 
tion would save animals when the same 
and even larger amounts given in divided 
doses would utterly fail. Cases of diph¬ 
theria were treated with one massive sub¬ 
cutaneous injection of antitoxin in which 
the antitoxin content of the blood was 
tested from hour to hour. It was found 
to increase in all cases for the first 3 days. 
The apparent improvement following a 
second dose of antitoxin was shown to be 
due, partly to the continued absorption ot 
the first injection, and partly to the neces¬ 
sary time required for recovery of the 
local process. When the first injection 
was of fair size, a second added no real 
effect. During 1912-1913, over 95 per cent, 
of all cases of diphtheria treated at the 
Willard Parker Hospital received but 1 
injection of antitoxin. The mortality was 
the lowest in the history of the hospital. 
The usual amount given was 5000 units 
in the milder cases, 10,000 units in the 
moderate or rather severe cases, and 
20,000 units in the malignant cases. In 
the latter, the antitoxin was given intra¬ 
venously whenever possible. The same 
number of units given intravenously was 
fully fourfold the value of the same 


606 


ANAPHYLAXIS. 


amount given subcutaneously. Intramus¬ 
cular injections had the advantage over 
subcutaneous, in the rapidity of absorp¬ 
tion, but v^hen fairly large amounts were 
given, it was difficult to insure that the 
antitoxin remains within the muscle. As 
a rule cases not requiriing intravenous in¬ 
jections could be treated by either the 
subcutaneous or intramuscular methods. 

Concerning the danger of anaphylaxis 
from primary subcutaneous injections, the 
same author submits the results obtained 
by the New York Health Department. 
Over 30,000 cases of diphtheria had been 
treated with antitoxin since 1895 in the 
contagious disease hospitals. There had 
been no fatal cases of anaphylaxis and 
only one in which dangerous symptoms 
developed. In over 100,000 persons in¬ 
jected outside of the hospitals, there had 
been but 2 fatal cases, in 1 of which 
marked status lymphaticus existed. In a 
great many children in the scarlet fever 
service, a primary immunization injection 
of diphtheria antitoxin had been followed 
by a second larger subcutaneous injection 
at a period at which anaphylaxis should 
be marked. In no case had any danger¬ 
ous symptoms developed. Unless, there¬ 
fore, there was a history of asthma, there 
seemed no reason to avoid the giving of 
a primary serum injection on account of 
fear of later having to give another in¬ 
jection, either in the near future, or after 
a number of years. 

[The words “status lymphaticus” and 
“asthma” are italicized because I consider 
the thymus as a leading malefactor in the 
lethal process. In a series of articles on 
this organ (New York Med. Jour., March 
6, 1915 to Feb. 5, 1916 inclusive) I urged 
that under the influence of excessive feed¬ 
ing its sponge-like tissues became greatly 
engorged, in part by cellular elements. 
Since then Lesne and Dreyfus found that 
anaphylactic death could be prevented in 
highly sensitized animals by starving them 
4 or 5 days before the toxogenic dose 
was administered. Again, as we shall 
see elsewhere, thymic death may occur 
during swimming, dancing, coitus, etc. 
From my viewpoint this is the result of 
a temporary rise of blood-pressure which 
causes sufficient congestion of an enlarged 
thymus to cause asphyxia by compressing 


the trachea—a factor which should be 
borne in mind in the present connection. 
Asthma and status lymphaticus are impor¬ 
tant danger signals; but they are not al¬ 
ways present, even though the thymus be 
greatly enlarged. The diagnostic signs of 
enlargement are described in the article 
on the Thymus in vol. viii.—C. E. de M. S.] 
Besredka, who has done some of the 
best work available on the subject, states 
that anaphylactic shock may be largely 
averted by heating the serum to 56° C., 
or by giving normal serum per rectum be¬ 
fore giving the subcutaneous dose, or, 
again, by giving a small subcutaneous dose 
before the larger dose, Vaughan, Jr. 
(Amer. Jour. Med. Sci., Feb., 1913) states 
that a preliminary dose of as little as 0.1 
or 0.2 c.c. (114 to 3 minims) suffices, the 
therapeutic dose being given a couple of 
hours later if no untoward effects follow 
the test dose. This measure does not al¬ 
ways protect. Thus Koch (Berl. klin. 
Woch., June 28, 1915) reported the sudden 
death of a child of 6, with scarlet fever 
and diphtheria, at once after injection of 
antistreptococcus serum, after a prelimin¬ 
ary small injection. The child had been 
injected with diphtheria antitoxin the third 
and sixth days of his illness, and the in¬ 
travenous antistreptococcus serum injec¬ 
tion was given the twentieth day. Noth¬ 
ing could be found to explain the sudden 
fatality but anaphylactic shock, except 
that the child was debilitated, its resisting 
powers at a low ebb. In such cases sero¬ 
therapy should be applied with special 
caution. 

[We have seen under “tests” that even 
the .yw^cutaneous test doses may evoke 
grave symptoms, and even death. We can 
ascertain the susceptibility of the patient 
by the uffracutaneous test without expos¬ 
ing the patient.—C. E. de M. S.] 

S. Wyard (Lancet, Jan. 20, 1917) states 
that by the injection of a subminimal dose 
the individual is thereafter rendered re¬ 
fractory for a time, during which further 
and even larger doses may be safely 
given. In man sensitization rarely, if 
ever, reaches such intensity as to cause 
reaction with 1 c.c. (16 minims) of blood- 
serum, so that in the use of diphtheria or 
tetanus antitoxin, if it be considered un¬ 
safe to inject a large dose at once, 0.5 to 


ANAPHYLAXIS. 


1.0 c.c. (8 to 16 minims) may be used as 
a preliminary injection, followed 5 or 6 
hours later by any. further dose that may 
be considered necessary. Should even 
greater rapidity be desirable, such a pre¬ 
liminary dose may be followed in 5 or 10 
minutes by a larger, and every 5 minutes 
or so afterward by steadily increasing 
amounts, whereby in a very short time 
enormous doses may be given, and with¬ 
out risk of anaphylactic shock. In the 
case of tetanus antitoxin where prophylac¬ 
tic doses were given, these were prac¬ 
tically all innocuous. 

The amount of serum actually employed 
varies from 3 to 5 c.c. (48 to 81 minims), 
according to the concentration of the 
sample. An interval of anything up to 5 
weeks between two such doses will never, 
according to the author, give rise to 
symptoms. About the sixth week, how¬ 
ever, hypersensitiveness may appear. 

In 3 cases of alimentary anaphyl¬ 
axis antianaphylaxis treatment proved 
effectual. Two were in children who 
developed urticaria after eating eggs, 
or certain other food. The third was 
a young man with attacks of asthma 
nearly every evening, 3 or 4 hours 
after eating. All seemed to be cured 
completely by taking 0.5 Gm. (7V2 
grains) of peptone V 2 hour before 
breakfast and dinner for 20 days, with 
appropriate dietetic restrictions. Jol- 
train (Bull, de la Soc. Med. des Hop., 
June 6, 1919). 

Agreeing with the view that ana¬ 
phylactic manifestations are due to 
the formation in the blood plasma, 
at the time of the second injection, 
of a colloidal flocculent precipitate 
which causes asphyxia by obstruct¬ 
ing the capillaries, the writers tried 
various substances which might pre¬ 
vent it. Among the few compounds 
found effectual, sodium hyposulphite 
was by far the least toxic. Control 
animals, unprotected by this salt, in¬ 
variably succumbed. Similar experi¬ 
ments with antidiphtheritic serum 
gave the same results. They deem 
addition of sodium hyposulphite in 
suitable amounts to therapeutic ser¬ 
ums a simple, practical and harmless 
means of obviating anaphylactic phe¬ 


607 

nomena. Lumiere and Chevrotier 
(Presse med., Nov. 6, 1920). 

The anaphylactic shock or colloido- 
clasie serique can be warded off by 
intravenous injection of 0.5 to 2 Gm. 
(7M> to 30 grains) of sodium car¬ 
bonate in 40 to 60 c.c. (l-i/^ to 2 
ounces) of saline or distilled water. 
Sodium bicarbonate by the mouth, 
10 to 15 Gm, (2M; to 3% drams) 15 
minutes beforehand, will ward off the 
anaphylactic shock to a less extent. 
Sicard and Paraf (Bull, de la Soc. 
Med. des Hop., Jan. 28, 1921). 

Treatment of Anaphylactic Reaction.— 
1 he term “anaphylactic shock” is occa¬ 
sionally employed in this connection, but 
is misleading, since an approach to true 
shock is only witnessed when the patient 
is virtually moribund, i.e., when his blood- 
pressure has fallen below normal. 

Anderson and Schultz found some years 
ago (1910), using highly sensitive guinea- 
pigs, that atropine sulphate, chloral hy¬ 
drate, plus urethane and adrenalin, pure 
oxygen, both alone or with chloral hy¬ 
drate and adrenalin, almost invariably 
prolonged life, but that it did not prevent 
their eventual death from low blood- 
pressure, though not from acute asphyxia. 
Rosenau and Anderson tried, besides these 
agents, ether, recommended by Besredka, 
paraldehyde and magnesium sulphate, but 
concluded that they had no influence on 
the outcome. Of these, atropine, adrenalin, 
iiTramuscularly or intravenously, chloral 
hydrate, ether and pure oxygen inhalations, 
and artificial respiration, might prove of 
service. A threatening case of anaphylaxis 
following the secondary use of cholera 
vaccine was successfully treated with ad¬ 
renalin by Parhon and Bazgan (Bull, de 
la Soc. de Jassy, Jan.-Apr., 1916). 

W. M. Crofton (Lancet, Jan. 20, 1917) 
found that 1 c.c. (16 minims) of pituitrin 
given at once relieves the collapse and 
spasm of the bronchioles within a few 
minutes. The dose is repeated if the 
symptoms show any signs of returning. 

Edema of the larynx was evidently pres¬ 
ent in a case reported by M. B. Arnold 
(Lancet, Jan. 27, 1917), in which tracheot¬ 
omy relieved all the respiratory phenom¬ 
ena and the cyanosis. 

[The main features of the morbid 


608 


ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 


process seem to me to have been over¬ 
looked. That an intoxication prevails is 
undeniable. Enhancing the osmotic prop¬ 
erties of the blood and its viscosity, intra¬ 
venous saline solution infusions, preceded 
perhaps by bleeding, is the rational meas¬ 
ure indicated. If the blood-pressure is low, 
as it is late, i.e., during the second stage, 
adrenalin should be added, the 1:1000 solu¬ 
tion being injected drop by drop with a 
hypodermic syringe into the rubber tube 
of the irrigating instrument. Intramus¬ 
cular injections of pituitrin may also be 
used.—C. E. DE M. S.] 

ANEMIA, PERNICIOUS PRO¬ 
GRESSIVE. — DEFINITION. — A 

form of anemia characterized by a 
progressive destruction of the red cor¬ 
puscles vrhich points to a fatal issue. 

SYMPTOMATOLOGY.— Per¬ 
nicious anemia develops insidiously, 
though an abrupt onset occasionally 
occurs, especially in pregnant or puer¬ 
peral women. The most evident 
symptom is pallor of the face and 
body, which gradually becomes ex¬ 
treme and assumes a lemon-yellow 
tint. This yellowish color deepens 
as the case progresses; it may appear 
suddenly, but in the majority of cases 
it develops gradually, following the 
insidious course of the disease. The 
mucosje are similarly affected. 

There is great weakness with all its 
attending symptoms: inordinate pal¬ 
pitations and dyspnea on exertion, 
sighing, and slow delivery in speak¬ 
ing. The pulse, which may be strong 
at first, is regular, but rapid, soft, and 
compressible, in the majority of cases, 
more or less fever being usually pres¬ 
ent. The temperature is extremely 
irregular. Slight evening pyrexia is 
seldom absent in advanced cases. 

Cardiac murmurs, especially of the 
hemic type, are usually to be heard, 
especially at the base, and signs of 


fatty degeneration may be detected by 
auscultation, although there is usually 
no arterial degeneration or valvular 
disease. A loud venous hum can 
sometimes be detected in the vessels 
of the neck, the so-called bruit de diahle 
with exaggerated cardiac impulse. 
Edema of the ankles, face, and lungs 
and dropsical effusions may appear at 
any stage. 

There may be hemorrhages into the 
mucous membranes, epistaxis, menor¬ 
rhagia, and purpuric eruptions in ad- 



Pundus ocuH in a case of pernicious anemia, 
showing retinal hemorrhages. {Bramwell.) 


vanced cases. Ecchymoses in the skin 
and mucous membranes are some¬ 
times noticeable in advanced cases. 
Retinal hemorrhages may occur. 

A study of 148 cases led the writer 
to conclude that while pernicious 
anemia has its own characteristic 
diagnostic findings, these may be sim¬ 
ulated closely by anemias resulting 
from various diseases, particularly in 
those due to some definite septic, 
toxic or malignant condition. The 
diagnosis should rest, not on the 
blood findings alone nor on the blood 
findings and symptomatology, but on 
both of these features in the absence 
of any discoverable cause for the ane- 



ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 


609 


mia. The disease is more common in 
males and is most frequent in the 
fourth and fifth decades of life. The 
cardiac symptoms and physical find¬ 
ings are among the most common 
symptoms. These findings are the 
result of myocardial weakness and 
relative insufficiency. 

The systolic pressure is almost 
never above normal, but tends to be 
below the lower limit of normal; the 
diastolic pressure is disproportion¬ 
ately low and the pulse pressure high. 
The urine is usually of a fairly low 
specific gravity, rather increased in 
quantity, and rarely contains albumin. 
Albumin with casts means nephritis, 
which may be the cause of the ane¬ 
mia rather than the effect. Pernicious 
anemia is characterized by an irregu¬ 
lar temperature, which is not often 
above 101°; there are often reces¬ 
sions to normal of variable duration. 
Achylia gastrica is so much the rule 
that the presence of free hydrochloric 
acid may raise a doubt as to the 
diagnosis. The gradual decrease in 
the leucocyte count, especially in the 
relative and absolute number of poly- 
morphonuclears, is of serious prog¬ 
nostic import. The diagnosis of per¬ 
nicious anemia should be made with 
the utmost reserve in the presence of 
a leucocytosis. J. G. Carr (Amer. 
Jour. Med. Sci., Nov., 1920). 

Gastric and intestinal disorders are 
the rule, although the general nutrition 
is apparently preserved, the appetite 
being sometimes voracious, and the pa¬ 
tient becoming obese. Nausea is fre¬ 
quently an early symptom. Dyspepsia, 
vomiting, and diarrhea usually prevail, 
though some cases suffer from consti¬ 
pation. The gastric region is tender to 
pressure, and the tongue is pale and 
smooth. Eructations and anorexia are 
common. Involvement of the osseous 
system is occasionally indicated by sen¬ 
sitiveness of the bones, especially those 
of the sternum. 

The familiar fact that this chronic dis¬ 
ease ends in death in practically every 

1 


case has rightly been attributed to the 
tardiness with which its true identity is 
recognized. So advanced have the lesions 
then become that remedial measures are 
of no avail. Efforts have been made, 
therefore, to discover initial symptoms. 
Schaumann (Deut. med. Woch., June 27, 
1912) emphasizes the importance of a 
sign first pointed out by William Hunter: 
soreness of the tongue and mouth, and in 
some cases of the throat, the organ re¬ 
maining moist and uncoated, though 
deeply grooved. These signs appear be¬ 
fore the blood gives any positive indica¬ 
tion of the nature of the disease. Zabel 
(Klin-therap. Woch., Jan. 6, 1913), who 
describes the lingual pain as burning, 
states that he has witnessed it in the 
simpler secondary anemias, but that it dis¬ 
appears in these disorders when the gen¬ 
eral condition improves. H. Stern (Deut. 
med. Woch., July 23, 1914) considers it the 
most reliable of the inaugural symptoms 
of true pernicious anemia. 

In 4 cases of the classic type, Rocca- 
villa (Policlinico, Sept., Med. Sec., 1916) 
noted burning heat and dryness of the lips, 
tongue and throat as the first sign of 
trouble. The complexion assumed a 
lemon yellow tint with greenish reflection 
in all but one of the patients. 

An authoritative clinician, Friedenwald 
(Boston Med. and Surg. Jour., Aug. 1, 

1912) noted that in a series of 58 cases all 
showed gastro-intestinal symptoms. There 
were loss of appetite, nausea, vomiting, 
indigestion (fullness, pressure, disten¬ 
tion), diarrhea and constipation. Achylia 
gastrica was present in about 70 per cent, 
of the cases and even in the stage of ap¬ 
parent recovery the gastric secretion did 
not return. 

Another feature in the early diagnosis 
of pernicious anemia worthy of closer ob¬ 
servation in the future is the occasional 
early predominance of nervous phenom¬ 
ena. Thus, in several cases seen by C. E. 
Riggs (New York Med. Jour., July 15, 

1913) mental symptoms recalling those of 
dementia paralytica and spinal symptoms 
resembling those of ataxic paraplegia had 
long preceded any of the blood character¬ 
istics. Wilson (Jour. Amer. Med. Assoc., 
Sept. 7, 1912) holds that if the spinal in¬ 
volvement, which, in a case of his own 

■39 


610 


ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 


consisted of degenerative vacuolization of 
the nerve-cells and replacement gliosis, 
were borne in mind, many cases that fail 
to be promptly recognized would clear up 
at once. The history of his case and the 
microscopic findings suggested the intes¬ 
tinal origin of both the pernicious anemia 
and the spinal disorder. On the whole, 
given a case in which yellowish pallor and 
lassitude are attended with oro-gastro- 
intestinal phenomena with remission and 
periodical gastralgia, a tentative diagnosis 
of the form of pernicious anemia most 
frequently encountered is warranted, even 
before the blood affords any clue to the 
identity of the disease. C. E. de M. S.] 

The respiration is usually acceler¬ 
ated, and dyspnea, air-hunger, and op¬ 
pression in the chest are frequent 
symptoms. Pericardial and pleural ef¬ 
fusions are sometimes observed. 

Drowsiness is present in the major¬ 
ity of cases, but insomnia is occasion¬ 
ally noted. The patient is readily 
fatigued and even exhausted on the 
least exertion. The weakness increases 
until attacks of faintness supervene. 
The patient ultimately becomes bed¬ 
ridden. 

Headache, vertigo, tinnitus, apo¬ 
plectiform attacks, delirium, and other 
disorders of the nervous system, such 
as paresthesia, neuralgia, and extensive 
paralyses, have been noted. Mental 
torpor, somnolence, peevishness, con¬ 
fusion, delirium, and various psychic 
phenomena may also occur. 

Absence of the knee-jerk is frequent, 
and is indicative of degeneration of the 
posterior columns of the cord. 

The presence of grave pernicious 
anemia is to be suspected when pul¬ 
sation of the inferior vena cava is dis¬ 
cernible. It is best recognized by 
simple inspection, especially in the 
median line below the umbilicus, 
somewhat more to the left than to 
the right, and is visible as a double, 
undulatory rise of the surface in each 
cardiac cycle. Palpation is negative. 


and the pulsations disappear when 
the patient rises from the recumbent 
to the sitting or standing posture. L. 
Bard (Semaine med.. Mar. 25, 1914). 

Jaundice is occasionally met with. 
The urine is dark and highly colored; 
it is of low specific gravity, and shows 
an increase of urea and uric acid and 
pathological urobilin. Indican may also 
be detected. 

When the end is approaching, the 
temperature, which in the course of the 
disease is apt to rise toward evening, 
sometimes reaching as high as 102° F. 
(38.8° C), recedes markedly, and the 
patient enters into a torpid condition 
ending in coma. 

BLOOD EXAMINATION.— Be¬ 
fore describing all the characteristics 
of the blood, a summary of its morbid 
changes may prove useful. Though 
sometimes dark and watery, the blood 
is, as a rule, pale. The red corpuscles 
are greatly reduced, sometimes as low 
as 143,000, though, as a rule, they do 
not go below 500,000. The percentage 
of hemoglobin is also greatly reduced, 
but not in proportion with that of the 
red corpuscles. The latter also show 
considerable alteration in size and 
shape. Some are large and ovoid 
(megalocytes) ; others are small, round, 
and dark red (microcytes), while oth¬ 
ers again are very irregular in shape 
(poikilocytes). Nucleated red cells, 
both normoblasts (normal in size) and 
megaloblasts (when very large), are 
a marked characteristic of the disease, 
while blood-plaques are either absent 
or present in very small number. The 
leucocytes, though relatively increased 
in respect to the red corpuscles, are 
usually normal in number, with the 
smaller mononuclear forms predom¬ 
inating. 

In the pernicious anemia compli¬ 
cating pregnancy the blood findings 


ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 


611 


in the mother are characteristic. The 
red cells are decreased in number, 
even to 250,000. The blood does not 
show a proportionate decrease in its 
hemoglobin content, but there is a 
marked alteratiorr in the shape, size, 
and staining of the individual cells. 
Macrocytes and microcytes abound 
and megaloblasts are occasionally 
present. Nucleated red cells do not 
as a rule appear until the disease is 
well advanced; they tend to appear in 
showers, and in some cases fail to 
appear or at least are not found even 
in the last stages of the disease. 
Poikilocytosis is marked; fibrin and 
blood platelets are diminished and the 
leucocytes are lessened in number. 
Palmer Findley (Trans. Amer. Gynec. 
Assoc.; N. Y. Med. Jour., Aug. 24, 1918). 

To understand these blood changes, 
however, they must be analyzed from 
the standpoint of their cause. The two 
prevailing theories as to the pathogen¬ 
esis of pernicious anemia are: 1. That 
the disease is due to breaking up of 
the blood-corpuscles (hemolysis). 2. 
That, owing to some defect in the 
blood-making (hemogenesis), the blood 
becomes vulnerable to the destructive 
influence of micro-organisms. At the 
present time the former view strongly 
prevails, the hemolysis, as urged by 
Grawitz, Hunter, Stengel, and others, 
being ascribed in great part to poisons 
absorbed from the alimentary canal, 
the disease being thus an autointoxica¬ 
tion. The toxics, according to Sajous, 
promote and sustain hemolysis by caus¬ 
ing an overproduction of antibodies, 
which not only destroy the pathogenic 
poisons, but also the red corpuscles. 
The hemosiderin found in the urine is 
the product of the broken down hemo¬ 
globin i.e., the iron freed of hematin. 

The writer regards hemosiderin 
granules in the urine as an aid to the 
diagnosis of both pernicious anemia 
and hemochromatosis. In a soldier 
of 46 years, showing hemochroma¬ 


tosis, the diagnosis between this con¬ 
dition and syphilis became doubtful. 
There was enlargement of the liver 
and spleen and a peculiar gray pig¬ 
mentation of the skin, and the urine 
was found to contain considerable 
hemosiderin granules. The patient 
died within 3 months with character¬ 
istic signs of hemochromatosis. The 
writer urged that hemosiderin gran¬ 
ules are also found in the urine in 
eight-tenths of the cases of pernicious 
anemia, provided fresh urine be used 
for the test. P. Rous (Trans. Assoc. 
Amer. Phys.; N. Y. Med. Jour., Aug. 
31, 1918). 

While the presence of hemosiderin 
granules does not explain the etiol¬ 
ogy of hemochromatosis, it tends to 
account for its pathology, which per¬ 
haps is the result of interstitial in¬ 
flammation of the pancreas, while the 
cirrhosis of the liver is probably 
secondary to accumulation of iron 
pigment in the cells. E. I. Opie 
(Trans. Assoc. Amer. Phys.; N. Y. 
Med. Jour., Aug. 31, 1918). 

In a patient of 67 years, with 
chronic jaundice, the writer found in 
the spleen and liver a hemosiderosis 
comparable with that shown hy Rous, 
but there was no cirrhosis of the 
liver. W. Tileston (Trans. Assoc. 
Amer. Phys.; N. Y. Med. Jour., Aug. 
31, 1918). 

Deficiency of red corpuscles (oligo¬ 
cythemia) is always very great; the 
blood is, therefore, pale and thin, re¬ 
sembling sherry wine. The oligocy¬ 
themia is sometimes so marked that the 
normal proportion of 5,0(X),()00 red 
corpuscles to the cubic centimeter is 
reduced to one-twenty-fifth of that 
number. Quincke reported a case in 
which, as previously stated, there were 
only 143,0{)0 to the cubic centimeter 
immediately before death. This is an 
important diagnostic feature. There is 
no disease, except pernicious anemia, 
in which the number of red corpuscles 
is at any time reduced below 20 per 
cent. This afifords a distinction between 


612 


ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 


pernicious anemia and latent gastric 
cancer, a disease with which the former 
is most likely to be confounded. 

The hemoglobin is also greatly re¬ 
duced (oligochromemia), but not in 
proportion with the cell reduction. The 
hemoglobin percentage was greater by 
10 per cent, in a case seen by Osier. 
The relatively high percentage of hem¬ 
oglobin depends upon increased aver¬ 
age size of the corpuscles and in some 
cases on the presence of an unusual 
number of highly colored and minute 
microcytes. It also depends, in a meas¬ 
ure, upon the time at which the ex¬ 
amination is made. The icteric color 
of the skin and the dark urine are 
caused by dissolution of the red blood- 
corpuscles, and the hemoglobin esti¬ 
mated at one of these periods will thus 
be higher. Owing to the more highly 
colored plasma. The red blood-cor¬ 
puscles show marked signs of reversion 
to the type of blood which is normal 
in the cold-blooded animals. 

There is also a species of degenera¬ 
tion closely resembling coagulation ne¬ 
crosis, and an alteration of the cor¬ 
puscles, characterized by the appearance 
in their interior of certain corpuscles 
composed of modified hemoglobin— 
degeneration hemoglohinemique. 

The process of regeneration is man¬ 
ifested by the presence of nucleated 
red corpuscles, which are divided by 
Ehrlich into two varieties: the normo¬ 
blasts and the megaloblasts, the former 
corresponding to the hematinic evolu¬ 
tion of adults, the latter to that of the 
embryo. The nucleus of the normo¬ 
blast is extruded to form a new red 
corpuscle, while the nucleus of the meg- 
aloblast is absorbed. Fresh blood 
shows nucleated red corpuscles of large 
size, the megalocytes and gigantocytes 
previously mentioned. 


Fiirbringer has shown that a case is 
to be considered as one of true per¬ 
nicious anemia only when one-fourth 
of the red corpuscles are macrocytes. 
The presence of megaloblasts is a sign 
that certain pathological changes are 
taking place in the red marrow rather 
than a distinctive feature of pernicious 
anemia. The macrocytes are more 
characterisic of pernicious anemia, be¬ 
cause they are the direct precursors of 
the large red-marrow cells. 

Misshapen corpuscles (poikilocytes) 
are very frequently observed, oftener, 
indeed, than in any .other affection. 
Many small, imperfectly developed 
corpuscles (microcytes) are generally 
found. 

In marked cases corpuscles endowed 
with motion are occasionally observed. 
According to Hayem, the red blood- 
corpuscles of normal blood are motion¬ 
less. Conversely, the elements observed 
in cases of high degree of anemia are 
endowed with four kinds of motion: 1. 
A movement of the entire mass of the 
corpuscle. 2. The projection of mo¬ 
bile prolongations. 3. A movement of 
oscillation, manifested slowly by minute 
corpuscles. 4. A movement which re¬ 
sults in changing the position of the 
corpuscles. These movable corpuscles 
are bodies arrested in their evolution 
and still retaining the contractile prop¬ 
erties of the hematoblasts from which 
the red corpuscles originate. On super¬ 
ficial examination they might readily 
be mistaken for parasites. 

Many years ago I observed distinct 
movements in the red corpuscles in a 
case of pernicious anemia, but made 
no public mention of the interesting 
fact. Senator has also called attention 
to the presence of small, mobile bodies 
observed staining the same as red cor¬ 
puscles and resembling fragments of 


ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 


613 


heniatin, thought to possess pathogno¬ 
monic value. 

PATHOLOGY. —In cases in which 
the urine is dark the latter is found to 
contain pathological urobilin: a sub¬ 
stance known to be derived from the 
disintegration of hemoglobin, and 
which, according to Hunter, is of high 
diagnostic significance. A peculiarity 
of this highly colored urine is that it 
presents a low specific gravity, averag¬ 
ing 1.014. Occasionally, however, the 
urine is habitually pale. The kidneys 
are often the seat of fatty infiltration, 
accompanied sometimes by thickening 
of the interstitial tissue. Urinary reten¬ 
tion, owing to the absorption of hemo¬ 
lysins, whether of renal or cystic origin 
—the latter in cases of enlarged pros¬ 
tate for instance—may also act as cause. 

After a study of 14 cases the 
writer concluded that in a severe 
case the renal function is disturbed 
much as it is in advanced chronic 
nephritis. The disorder of excretion 
seems to be either a nutritional or a 
toxic disturbance in renal cellular 
activity. There is no other evidence 
of chronic nephritis in these cases, 
and the disturbance decreases with 
improvement in the anemia, unless 
the latter has been permanently dis¬ 
turbed. H. A. Christian (Arch, of 
Internal Med., Oct., 1916). 

The gastric and intestinal disorders 
are probably due to the formation of 
poisons, which, we have seen, act, in 
turn, as the etiological factors of the 
general disease. The gastric and in¬ 
testinal walls are often found to be the 
seat of fatty change, and atrophied. 
Intestinal entozoa underlie many cases. 

With the aid of the Abderhalden 
reaction the writer reached the con¬ 
clusion that there exists a definite 
causal relation between pernicious 
anemia and gastrointestinal disturb¬ 
ances. This suggests that autointoxi¬ 
cation of gastrointestinal origin is 


an important pathogenic factor in 
the process. Kabanoff (Roussky 
Vratch, Sept. 7, 1913). 

A study of the chemistry of per¬ 
nicious anemia showed that it may 
be considered as the result of a gas¬ 
trointestinal disturbance leading to 
destruction of mucosa sufficient either 
to allow undigested proteins to leak 
through into the blood stream, 
where their partial digestion liberates 
protein poisons, or to the absorption 
of known hemolytic toxins produced 
in the course of intestinal putrefac¬ 
tion, such as, e.g., p-oxyphenylethy- 
lamin. In either case, the poison has 
a destructive influence on the intes¬ 
tinal mucosa, as well as the more evi¬ 
dent hemolytic effect, and this re¬ 
sults in the establishment of a vicious 
circle. Sqeier (Jour. Lab. and Clin. 
Med., May, 1917). 

Pernicious anemia may be due to an 
infection of the intestinal tract with 
the Bacillus aerogenes capsulatus. Her- 
ter found this organism regularly and 
in large numbers in the fecal matter' 
of patients with pernicious anemia, 
whereas in ideal conditions of human 
digestion the organism is present only 
in small numbers. 

Tallqvist has shown that Dibothrio- 
cephalus latus, which may cause an 
anemia similar to pernicious anemia, 
contains a powerfully hemolytic lipoid 
which can be extracted from the body 
of the worm, and has been able to 
demonstrate quite similar substances in 
the mucosa of the human digestive 
tract. 

In the cryptogenetic form of per¬ 
nicious anemia it is very exceptional 
to find free HCl in the stomach con¬ 
tents. In 42 cases seen in their in¬ 
ternal service in the University of 
Helsingfors the writers fully con¬ 
firmed this fact. In but one of these 
series was there free acid present. 
In the bothriocephalus type, on the 
contrary, 17 per cent, of 57 cases 
showed the presence of free HCl in 


614 


ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 


the stomach contents. After the ex¬ 
pulsion of this tapeworm this per¬ 
centage rose to 43.8 per cent. Even 
this figure is doubtless too low; it is 
at least 50 per cent., i.e., in every 
second case of bothriocephalus ane¬ 
mia free HCl reappears in the stom¬ 
ach after the disease has been cured. 
Schauman and Levander (Finska 
Lakare. Handlingar, Feb., 1917). 

The spleen is generally thought to 
present no characteristic lesion, al¬ 
though the amount of iron in it is usu¬ 
ally increased. It may, however, be 
slightly enlarged, and be the seat, as ob¬ 
served by Stanley, of sclerotic changes, 
along with similar changes in the pan¬ 
creas and adrenals. 

Changes in the spleen and liver 
similar to those described by Meyer 
and Heinecke in man in pernicious 
anemia and in other severe anemias 
may be produced in animals by the 
administration of hemolytic sub¬ 
stances; the writer’s results confirm 
those obtained by Morris. In some 
instances, especially in chronic ane¬ 
mias with degeneration, the liver and 
spleen both resembled the organs of 
the embryo at the stage when these 
organs are engaged in hematopoiesis. 
Domarns (Archiv f. exper. Path. u. 
Pharm., Bd. Iviii, S. 319, 1908). 

Jaundice is probably due to accumu¬ 
lation of iron in the hepatic system. In 
a case studied by Ruttan and Adami, 
the total quantity of iron found in the 
liver was 0.2433 per cent, by weight 
calculated to the fresh undried tissue. 
This is equivalent to about 0.72 per 
cent, to the dried tissue. The estima¬ 
tion accords fully with the observations 
of previous observers, as showing the 
very great increase in the iron con¬ 
tained in the liver in this disease. Kely- 
nack and Coutts found it to be five 
times greater than normal. The iron is 
mainly deposited about the periphery 
and middle zone of the lobules, and is 
derived from the vast number of de¬ 


stroyed red corpuscles. The kidneys, 
spleen, pancreas, hemolymph-glands are 
also laden with iron-pigment derived 
from these cells. 

A study of 20 cases showed that 
bile pigment is frequently found in 
the blood in pernicious anemia, and 
is the cause of the jaundice. The bile 
pigment is in some way fixed to the 
plasma, and therefore does not ap¬ 
pear in the urine. The presence of 
bile pigment in the blood is not al¬ 
ways betrayed by jaundice. Bile 
salts are frequently found in the 
blood, alone or associated with bile 
pigment. Blankenhorn (Arch, of In¬ 
ternal Med., Mar., 1917). 

[I have pointed out that bilirubin cor¬ 
responds in its chemical properties with 
the adrenal principle. Hence its presence 
in the blood. C. E. de M. S.] 

The posterior and lateral spinal 
tracts present changes resembling those 
observed in tabes, but most marked in 
the posterior lateral columns, as ob¬ 
served by Nonne, and to a less degree in 
the lateral columns. All these changes 
are not typical of pernicious anemia, 
however, and may be met with in 
other diseases in which cachexia and 
marasmus predominate, such as Addi¬ 
son’s disease and diabetes. Hemor¬ 
rhagic areas in the cord and brain due 
to hyaline degeneration of the blood¬ 
vessels are also met with. We have 
seen that retinal hemorrhages consti¬ 
tute a diagnostic feature of the disease. 

Two cases illustrating 2 of the 
types of nervous-system involvement. 
In the first case, which had the long¬ 
er and more pronounced history of 
anemia, the nervous symptoms were 
at a minimum and the posterior col¬ 
umns of the cord, particularly in the 
cervical region, alone showed degen¬ 
eration, characteristically patchy in 
distribution. In the second case, the 
nervous involvement, particularly in 
the later stages, overshadowed the 
anemia. Here the spinal cord pre- 


ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 


615 


sented very extensive, yet incomplete 
degeneration with slight replacement 
gliosis in the posterior columns, and 
also a similarly irregular, but more 
diffuse degeneration in the lateral 
tracts, which, however, was a rather 
less complete and apparently some¬ 
what more recent process. Camac 
Milne (Amer. Jour. Med. Sci., Oct., 
1910). 

The writer examined the brains of 
7 persons who died of primary idio¬ 
pathic pernicious anemia. The most 
salient features in the pathologic 
anatomy of these brains, were the 
following: 1. Not only do degener¬ 
ated areas of the Lichtheim type, 
such as are typically found in the 
posterior and lateral funiculi of the 
spinal cord in pernicious anemia pa¬ 
tients, occur in the medullary por¬ 
tions of the brains of these cases, but 
they occur with about the same fre¬ 
quency, though their demonstration 
may be rendered more difficult. 2. 
Patients who show degenerative 
changes in the spinal cord at nec¬ 
ropsy, usually show the same type 
of lesion in the brain also. 3. In 
addition to these focal degenerative 
areas found in the white matter, 
which may or may not be associated 
with blood-vessels, one also finds a 
diffuse degeneration, which, though it 
is, as a rule, somewhat more striking 
in the long association tracts, also 
occurs in the short commissural fibers 
passing from one gyrus to another, 
thus rendering the view untenable 
that it is the distance of these fibers 
from their trophic centers which is 
instrumental in causing the degenera¬ 
tion. 4. The gray matter is by no 
means immune from the destructive 
process. This is usually focal in 
character, and begins around the 
pyramidal cells of the marginal gray 
layer, the cells themselves being ulti¬ 
mately destroyed in the process, this, 
in turn, giving rise to a secondary 
and very diffuse degeneration of the 
medullated fibers in the white mat¬ 
ter. 5. Though some degeneration 
was noted in the fibers of the inter¬ 
nal capsule and in the long tracts 


passing through the pons, the degen¬ 
eration at this level was less intense 
than that seen either in the cord or 
in the brain. 6. The appearance of 
these plaques, not only around the 
blood-vessels but also around some 
of the larger pyramidal cells, seems 
additional evidence that lymph stasis 
is an important factor in the produc¬ 
tion of these foci. 7. Well marked 
psychoses, such as are occasionally 
associated with pernicious anemia, 
probably have little or nothing to do 
with these destroyed areas. 8. The 
milder mental manifestations such as 
somnolence, apathy, and terminal 
delirium, are probably in a measure 
dependent on these lesions, though 
the chief causative agent of these 
symptoms is probably the toxin 
itself. Woltman (Arch, of Internal 
Med., June, 1918). 

The bone-marrow usually presents 
changes which indicate abnormal activ¬ 
ity, being composed mainly, when the 
case is not too far advanced, of hemat- 
oblasts, as emphasized by Rindfleisch. 
It resembles in this state, as noted by 
H. C. Wood, Pineau, and others, the 
hemoblastic marrow of childhood. 
Other changes frequently found, ac¬ 
cording to Muir, are (a) increased 
number of nucleated red corpuscles in 
the marrow; (b) transformation of the 
fatty marrow in the shafts of the long 
bones into red marrow; (c) absorption 
of the bone trabeculae between the red 
marrow. Later, it presents all the 
signs of excessive compensative func¬ 
tion, being actually hypertrophied in 
some instances. When this stage is 
reached the bone-marrow may lose its 
power to create red corpuscles. 

The proteids of the plasma may be 
altered in their respective proportions, 
and considerably reduced—40 per cent, 
below the average normal quantity, ac¬ 
cording to Ruttan and Adami—the 
globulins being especially reduced. 


616 


ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 


Although fatty degeneration is pres¬ 
ent in practically all organs, emacia¬ 
tion is exceptional, though the adipose 
tissue is pale and yellowish, contrast¬ 
ing with the usually red muscular tis¬ 
sue. The heart, however, is enlarged 
and flabby, and its muscular elements 
are pale, friable, and fatty, its cavities 
containing light-colored blood. The 
general fatty degeneration afifecting 
markedly the vessel walls, these are 
extremely friable; hence, the hemor¬ 
rhages, retinal, cutaneous, etc., and the 
ecchymoses so frequently witnessed. 

DIAGNOSIS. — While pernicious 
anemia possesses characteristics that 
readily distinguish it from other blood 
affections,—the color of the skin, the 
retinal hemorrhages, etc.,—the early 
stages are generally such as to sug¬ 
gest less dangerous diseases. 

Benign Anemia.—Intractability of 
the disease, after the removal of sup¬ 
posed causes and the faithful use of 
appropriate measures of treatment, 
strongly suggests pernicious anemia. 

Chlorosis.—From this affection per¬ 
nicious anemia may readily be differ¬ 
entiated by the blood examination. 
Instead of relative increase of hemo¬ 
globin, the presence of gigantobasts, 
marked oligocythemia, and macro¬ 
cytes differentiate. 

The erythrocytes, or red corpuscles, 
in chlorosis, may be normal in num¬ 
ber and size, the only change being a 
deficiency of hemoglobin. Again, the 
corpuscles may be normal in number, 
but diminished in size, while the per¬ 
centage of hemoglobin is normal; 
finally, the corpuscles may be dimin¬ 
ished in number with either a dimin¬ 
ished, normal, or perhaps an increased 
percentage of hemoglobin. 

Leukemia.—This disease may be 
excluded by the absence of the char¬ 


acteristic blood-change: excess of 
white corpuscles. 

In a case of leukemia the patient 
often does not show enough pallor to 
make the physician suspect the dis¬ 
ease. The lips have a dirty-red color 
rather than a peculiar pallor. The 
number of white corpuscles would 
cause pallor in a patient with simple 
anemia, but in this disease the opacity 
of the blood is great and the pallor 
fails to show. 

Pseudoleukemia is excluded by the 
absence of the affection of the lym¬ 
phatic glands which characterizes 
this disease, more commonly known 
as Hodgkin’s disease. 

Gastric Cancer.—This condition al¬ 
most always shows itself after the age 
of 40 years, whereas pernicious ane¬ 
mia is sometimes observed earlier in 
life. In cancer the skin is pale; in 
pernicious anemia the peculiar lemon 
color is striking in the majority of 
cases. While ,gastric symptoms and 
absence of hydrochloric acid are 
prominent features of cancer, the di¬ 
gestive disorder is slightly marked in 
anemia and examination of the gas¬ 
tric contents is negative. The reduc¬ 
tion of red cells is greater in perni¬ 
cious anemia than in cancer. The re¬ 
duction of hemoglobin relative to 
corpuscles is not so great in pernicious 
anemia as in cancer. The average 
size of red cells is greater and poly- 
chromatophilia is marked. 

In grave anemia in 11 cases of 
nephritis with uremia, the anemia 
masked the renal disease. The ane¬ 
mia seems usually the result of the 
uremia and fluctuates with it. Cases 
of pernicious anemia may be mis¬ 
taken for arteriosclerosis. In doubt¬ 
ful cases of arteriosclerosis, especially 
those with a history of remissions, 
frequent blood counts and neurologic 
examinations for cord changes should 


ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 


617 


be routine procedures. Aubertin and 
Yacoel (Presse med., July 10, 1920). 

[It should not be forgotten that the 
causative toxemia in nephritis, arterio¬ 
sclerosis, and other conditions may like¬ 
wise produce through hemolysis all the 
symptoms of pernicious anemia. S.] 

Finally, increasing emaciation at¬ 
tends a cancerous disorder, whereas 
in cases of pernicious anemia the pa¬ 
tient not only retains his adipose tis¬ 
sues, but sometimes becomes corpu¬ 
lent. In rare cases, however, there 
has been extreme emaciation. 

The pernicious anemia of infants— 
a rare condition—is recognized, ac¬ 
cording to Rotch and Ladd, through 
the following diagnostic points : The 
insidious onset with moderate and 
paroxysmal attacks of indigestion, the 
extreme pallor, great loss of strength, 
slightly elevated temperature for 
months, and absence of glandular or 
splenic enlargements or of any demon¬ 
strable cause for a secondary anemia. 
The signs which are almost pathogno¬ 
monic in adults lose significance, on 
account of the greater instability of 
the infant’s blood-making function. 
Megaloblasts, normoblasts, macro¬ 
cytes, and poikilocytes may occur in 
grave anemias other than “pernicious,” 
yet are needed for diagnosis. 

ETIOLOGY. —The main patho¬ 
genic factor, hemolysis, has been re¬ 
viewed under a preceding heading; we 
still have to consider, however, the 
conditions which either predispose to 
the disease or are capable of causing it. 

As to predisposing agencies, al¬ 
though the disease occasionally occurs 
in children and young adults, it is 
most common at about the age of 40 
years. Males are attacked more fre¬ 
quently than females, with a slight 
difference in favor of the former. The 
disease is more prevalent among the 


better than in the lower classes, and 
is most common in Europe, especially 
in Switzerland, e.g., in regions in 
which the people are badly fed and 
live in poorly ventilated and badly 
lighted houses. Fright and grief are 
prominent etiological factors. Syph¬ 
ilis, sarcoma, and other disorders cap¬ 
able of impairing hematopoietic func¬ 
tions of the bones are also capable 
of bringing on the disease. 

According to Grawitz, the following 
group of etiological factors has been 
established: 1. Gastrointestinal dis¬ 
ease of long standing, poor food, im¬ 
paired digestion; chronic constipation, 
especially in women frequently preg¬ 
nant; irregular defecation in women 
and girls, especially those of hysteri¬ 
cal temperament. In such cases it is 
due to intoxication from the gastroin¬ 
testinal tract. 2. Pregnancy. Here, 
too, probably, there is an autointoxi¬ 
cation from the intestinal tract, on ac¬ 
count of pressure exerted.by the gravid 
uterus on the bowel. 3. Chronic hem¬ 
orrhages, especially of small size. 4. 
Constitutional syphilis, particularly 
wFen associated with sclerosis of the 
marrow of the long bones. 5. Bad 
hygienic conditions of various kinds, 
especially in the female sex; hard 
work, with insufficient food, bad air, 
and emotional excitement. In higher 
social strata the disease may be found 
in women who are subjected to intense 
mental strain as the result of a desire 
to equal men in physical efforts. Fre¬ 
quent pregnancy and prolonged lacta¬ 
tion are also factors. 6. Chronic poi¬ 
soning, as, e.g., by carbon monoxide. 
7. Bothriocephalus and ankylostomum 
—those cases belong here that are not 
cured after the expulsion of the worms. 

Pernicious anemia is not a specific 
entity, but a clinical syndrome of 


618 


ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 


varying etiology. Etiologically, the 
disease can be considered as crypto- 
genetic, or of concealed origin. 

' Under the former the writers group: 
(1) repeated hemorrhage (gastric, 
uterine, nasal, and vesical); (2) intes¬ 
tinal parasites (bothriocephalus and 
ankylostoma); (3) malaria; (4) bac¬ 
terial infections; (5) tuberculosis; 
(6) syphilis; (7) cancer, especially 
gastric; (8) gastrointestinal disor- ■ 
ders and autointoxications, which are 
said to be the cause of the so-called 
idiopathic cases; (9) nephritis; (10) 
pregnancy; (11) lead; (12) carbon 
monoxide, arsenic, and opium. The 
factors necessary for any of the 
above conditions to result in this 
syndrome are (a) an excessive inten¬ 
sity of the morbid cause; (b) the 
localization of the infection; (c) the 
duration or repetition of the cause; 
(d) an accumulation of the morbid 
condition; (e) predisposition. On the 
whole, progressive pernicious ane¬ 
mia can be the final stage of second¬ 
ary anemias. Ladd and Salomon 
(Revue de med., April and May, 
1908). 

Three cases of severe anemia wi’t- 
nessed due to repeated small bleed¬ 
ings and occasionally larger ones 
from varicosities situated 10 to 15 
cm. above the anus which could 
easily be seen with the proctoscope. 
Destruction of these varicosities by 
the Paquelin cautery rapidly cured 
the anemia. C. A. Ewald (Berl. klin. 
Woch., Jan. 9, 1911). 

Pregnant women represent the larg¬ 
est proportion of cases. Repeated par¬ 
turition is probably the most prolific 
cause of the disease, for it is seldom 
met with in primiparse. Excessive and 
prolonged lactation and puerperal hem¬ 
orrhages and other exhausting condi¬ 
tions frequently appear as the primary 
element in the causation of the disease. 

Two cases of severe anemia in 
pregnant women in which marked 
improvement followed delivery in 1 
case, and by the return of the ane¬ 
mia at each pregnancy in the other 


case. Weidenmann (Corresp. blatt f. 
Schweizer Aerzte, May 25, 1918). 

Anemias which are met with dur¬ 
ing pregnancy dififer from true per¬ 
nicious anemia and seem to owe 
their origin to the pregnancy itself. 
The first symptoms are scarcely ob¬ 
served before the second half of 
pregnancy. After labor it most fre¬ 
quently undergoes a rapid aggrava¬ 
tion, but in some cases it clears up. 
The prognosis is very grave, and 
medical treatment is generally in- 
efifective. E. Petersen (Arch. mens, 
d’obstet. et de gynec., vii, 1, 1918). 

In reporting a case the writer 
states that a review of the literature 
leads very directly to the conclusion 
that pregnancy and the puerperium 
favor the development and hasten the 
course of pernicious anemia. While 
pernicious anemia is not a disease 
peculiar to pregnancy it is neverthe¬ 
less true that the disease occurs with 
unusual frequency in the course of 
pregnancy and the puerperium. Just 
what the predisposing factors are in 
pregnancy is not known. Prolonged 
lactation, frequent child-bearing, the 
toxemias of pregnancy, and unfavor¬ 
able hygienic surroundings are fac¬ 
tors to be reckoned with but are not 
conclusive. P. Findley (Trans. Amer. 
Gynec. Soc., May, 1918). 

Certain atrophic conditions of the 
gastric mucous membrane, ulcers of 
the stomach, malaria, syphilis, cancer, 
and alcoholism have also been consid¬ 
ered as etiological factors. 

Pyorrhea alveolaris and carious teeth 
are increasingly asserting their role as 
sources of toxins which promote the 
disease. 

Contrary to the prevailing belief and 
the assertions of Ehrlich and Lazarus, 
pernicious anemia may be a family 
disease. 

Series of cases which all occurred 
in the same family—all fatal—in 2 
brothers, 1 sister, a paternal cousin 
and a paternal uncle. Blood exami¬ 
nations made in all established the 


ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 


619 


diagnosis beyond a doubt. Patek 
(Jour. Amer. Med. Assoc., Mar. 6, 
1911). 

The writer observed 5 instances in 
one family, the father, mother, and 3 
sons. C. J. Bartlett (Jour. Amer. 
Med. Assoc., Jan. 18, 1913). 

PROGNOSIS.—The disease as a 
rule ends fatally and in no given case 
can a favorable prognosis be given. 
It is true that under arsenic and other 
measures recoveries take place, many 
of which last over a period of years. 
Relapses, however, are to be expected. 

About one-half of the fatal cases 
last from one to six months; the re¬ 
maining seldom reach beyond the sec¬ 
ond year. Periods of transitory im¬ 
provement of varying duration are 
often a part of the natural course of 
the disease; so that too much impor¬ 
tance must not be attached to the favor¬ 
able results that may follow the special 
line of medication employed. Even if 
such improvement continues for a long 
time, the conclusion must not be too 
hastily reached that the disease is 
cured. According to Goodall, the prog¬ 
nosis may to a certain extent be based 
upon certain characteristics of the 
course of the blood-picture:— 

1. Acute Favorable Cases.—In these 
the symptoms are marked; the red cells 
are much diminished, but show a tend¬ 
ency to rise; the megaloblasts are atyp¬ 
ical and not numerous; the normoblasts 
are numerous; the color index is high, 
but tends to fall; the polychromato- 
philia is not marked; the percentage of 
polymorphonuclear cells is high; the 
myelocytes are absent or scanty. 

Course .—A remission to a fairly 
normal condition may occur, which 
may be maintained for years. 

2. Chronic Cases.—In these the 
symptoms are not well marked; the red 
cells tend to remain about one or two 


million; the megaloblasts are absent or 
scanty; the normoblasts are absent or 
scanty; the color index is generally 
low; the polychromatophilia is slight; 
the percentage of lymphocytes js high; 
the myelocytes are scanty. 

Course. —The cases are apt to be 
chronic. The patients can work, 
though they feel weak, and, though 
febrile attacks, etc., may occur, they 
have little bad effect. Improvement 
seldom occurs, but the duration may 
be for several years. 

3. Subacute Casesw—In these the 
symptoms are fairly well marked; the 
red cells about one million, showing 
slow and irregular tendency to rise; the 
megaloblasts are numerous; the normo¬ 
blasts are less numerous than megalo¬ 
blasts ; the color index is high; the 
polychromatophilia is distinct; the per¬ 
centage of lymphocytes is high in the 
absence of fever; the myelocytes are 
fairly numerous. 

Course. —Symptoms improve; blood 
improves to a certain extent. The 
duration is about two years, unless com¬ 
plications reduce this period. 

4. Acute Unfavorable Cases.—In 
this type the symptoms are marked, 
and there may be hemorrhages; the red 
cells are about one million, and tend to 
remain or go lower; the megaloblasts 
are typical and numerous; the normo¬ 
blasts are less numerous than megalo¬ 
blasts ; the color index is high; the 
polychromatophilia is marked; the per¬ 
centage of lymphocytes is high in the 
absence of fever; the myelocytes may 
be numerous. 

Course. —A fatal termination is to be 
expected in a few months. 

The tendency to relapse is in re¬ 
ality due to the remarkable persist¬ 
ence of the specific hemolytic infec¬ 
tion underlying the disease, since it 


620 


ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 


is always accompanied by a recru¬ 
descence of the lesions in the tongue, 
stomach, or intestine, and by the 
glossitic, gastric, or intestinal symp¬ 
toms connected therewith. Hunter 
(Brit. Med. Jour., Nov. 9, 1907). 

The immediate prognosis in certain 
cases of pernicious anemia with blood 
depletion below 400,000, although 
serious, is not hopeless. The prog¬ 
nosis depends on the degree of red¬ 
cell regeneration in the bone-marrow; 
the age of the individual and the 
potency of the hemolytic poison be¬ 
ing important factors. Stone (Jour. 
Amer. Med. Assoc., April 18, 1908). 

Report of 3 cases of pernicious 
anemia with remissions, with tabu¬ 
lated blood-counts. In one case the 
improvement followed the removal of 
the patient from the county farm to 
the hospital, where the better hy¬ 
gienic and dietary conditions were 
undoubtedly a strong factor. In sev¬ 
eral cases observed, out of a total of 
25 in the last two and a half years, 
in which fermentative changes in the 
intestines were a prominent symp¬ 
tom,* high colonic irrigations with 
physiological salt solution seemed to 
be connected with remissions of im¬ 
provement. Though the blood-count 
shows a marked improvement in the 
remissions, there are still abnormal 
features indicating that a disturbance 
in hematogenic function still exists. 
At best a remission is but a partial 
cure, and reserve in prognosis and 
caution in interpreting apparent 
therapeutic results are always advis¬ 
able. W. L. Bierring (Jour. Amer. 
Med. Assoc., Aug. 1, 1908). 

Case of pernicious anetnia in which 
there was a period of complete re¬ 
mission of symptoms, amounting to 
a cure for some sixteen years, with 
final relapse showing all the charac¬ 
teristic symptoms and pursuing a 
truly progressive course to a fatal 
ending. A. McPhedran (Amer. Jour. 
Med. Sci., Aug., 1910). 

Nageli has reported complete re¬ 
covery for 11 years to date in 2 cases 
and for 5 years in another case. Two 


of his patients bore other children 
later with no return of the anemia. 
The mortality is high among the chil¬ 
dren simply because anemia brings 
on premature delivery. Schuepbach 
(Correspondenzbl. f. Schweizer Aerzte, 
Bd. xliii, nu. 45-47, 1913). 

Case in a primipara, of 22 years, in 
whom the blood-picture was typical. 
As a result of a spontaneous miscar¬ 
riage she was immediately relieved of 
all her symptoms. The child was 
prematurely born, asphyxiated, and 
died after lj4 hours. The patient re¬ 
mained entirely free from symptoms. 
Wolff (Deut. med. Woch., Mar. 26, 
1914). 

TREATMENT.—Arsenic cures the 
curable cases and benefits the others. 
Iron is worse than useless, having 
shown itself injurious in several cases 
reported—doubtless because the liver 
is already overladen with iron. Fowl¬ 
er’s solution may be given in 3-minim 
doses three times a day, increased by 1 
minim daily until 30 minims are taken 
after each meal, provided the stomach 
does not rebel, which is seldom the 
case. The patient should be watched 
and the drug reduced or discontinued 
temporarily on the appearance of any 
of the physiological effects of arsenic: 
edema of the lids, etc. In some in¬ 
stances the doses have been increased 
with marked benefit until as much as 
20 drops were taken at a dose. • 

The cause of the hemolysis must be 
carefully sought and removed. It is be¬ 
cause this phase of the treatment of the 
disease is often overlooked that its 
prognosis is so unfavorable. 

Considerable importance is at¬ 
tached by the writer to oral sepsis, 
particularly that known to underlie 
various disorders of toxemic origin, 
pyorrhea alveolaris. Carious teeth 
should be removed, and, if there is 
pyorrhea alveolaris, the affected teeth 
taken out; if the patient’s condition 


ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 


621 


does not permit, local antiseptic 
treatment, together with an autogen¬ 
ous vaccine, may be tried. W. H. 
Wilcox (Pract., Sept., 1913). 

[In the article on Riggs’s Disease, pyor¬ 
rhea alveolaris, in the eighth volume, will 
be found other efficient methods for 
the prevention of toxemia due to this 
cause. S.] 

The writers recommend removal of 
all ascertainable foci of infection, an 
abundant roborant diet, arsenical 
treatment, the administration of hy¬ 
drochloric acid immediately after 
meals, and of pancreatin and calcium 
carbonate 3 hours after each meal. 
Splenectomy and transfusions of 
blood were not found necessary. 
Several of the patients thus treated 
have remained well over a long 
period. L. F. Barker and T. P. 
Sprunt (Trans. Amer. Med. Assoc.; 
N. Y. Med. Jour., June 9, 1917). 

The writer had 24 cases in which 
operations to eliminate pathogenic 
foci had been resorted to. The 
regions in which the foci were found 
were the gall-bladder, the appendix, 
and the mouth and throat. Of the 24 
cases, 14, or 58 per cent., were all 
clinically in good condition after in¬ 
tervals since operation varying from 
about 7 to 32 months. This latter 
case is perfectly well and carries no 
evidence of pernicious anemia in her 
blood, except an occasional normo¬ 
blast. In all cases except one in 
which the disease has recurred, the 
patient presented mental, nervous or 
spinal cord symptoms when they 
came under treatment, and in most 
of them these symptoms occurred 
early in the disease. It would seem 
that in all cases with involvement of 
the spinal cord and central nervous 
system, the prognosis is extremely 
bad under any form of treatment. 
Such patients should not be submit¬ 
ted to operation. Percy (Surg., 
Gynec. and Obstet., May, 1917). 
According to Grawitz, rest in bed is 
one of the first requisites; the assimi¬ 
lation of food must be stimulated. The 
patient should be placed on a milk and 


vegetable diet. Lavage of the stom¬ 
ach, intestinal irrigation, and saline 
laxatives are useful. If the urine con¬ 
tains much indican intestinal antisep¬ 
tics are indicated. Pie also regards 
arsenic as the best remedy; it can be 
given with quinine. Inhalations of 
oxygen have been employed with ad¬ 
vantage. Massage and gymnastic ex¬ 
ercises are often of service. After 
apparent recovery the patient must be 
carefully watched, as relapses may oc¬ 
cur, particularly if the hygienic and 
dietetic conditions are unfavorable. 

Case of pernicious anemia treated 
by Grawitz’s method. The patient 
was a man 33 years old who was ad¬ 
mitted to the hospital after suffering 
for' five weeks from anemia and 
weakness. All the symptoms mani¬ 
fested by the patient were that of a 
typical case of pernicious anemia. 
Treatment consisted of a strict diet 
of milk and vegetables, daily ene- 
mata, with arsenic and hydrochloric 
acid given by the mouth. Lavage of 
the stomach was not performed, 
owing to the patient’s objections. 
After eight weeks in the hospital and 
a month’s holiday in the mountains 
his general condition was excellent. 
Nicolayson (Lancet, Nov. 7, 1908). 

During overfeeding, symptomatic 
improvement took place with distinct 
betterment in the blood picture in 3 
cases observed by the writer. A diet 
allowing from 60 to 65 calories per 
kilogram (approximately double the 
minimum requirement) is recom¬ 
mended, this to be given in the ratio 
of protein, 16 per cent.; fat, 42 per 
cent., and carbohydrates, 42 per cent. 
Peppard (Minn. Med., Sept., 1919). 

When the gastric disorder, which 
is a usual symptom, prevents the ad¬ 
ministration of arsenic, the latter 
may be given subcutaneously, while 
the stomach is treated directly by 
lavage. Or, salvarsan or neosalvarsan 
might be tried. 


622 


ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 


In 1 of several cases in which sal- 
varsan proved effective, the patient 
had no history of syphilis, and gave 
a negative Wassermann in the serum 
and spinal fluid before the salvarsan 
was given. And yet this patient, who 
was in his fifth relapse, quite unre¬ 
sponsive to Fowler’s solution and 
only showed a very slight improve¬ 
ment after four months of sodium 
cacodylate injections, showed after 
the intravenous administration of 
salvarsan, in doses of 0.3 Gm. (5 
grains), every 4 weeks, a steady rise 
in the blood-count. The red cells, in 
16 weeks, rose from 500,000 to 5,- 
000,000, the hemoglobin from 23 per 
cent, to 90 per cent., and the patient’s 
general condition was much im¬ 
proved. It is evident that it is as a 
powerful arsenical preparation, i.c., 
as arsenobenzol, that salvarsan acts, 
and that as such it should command 
even greater confidence than in the 
past. Boggs (Bull. Johns Hopkins 
Hosp., xxiv, 322, 1913). 

In a case of pernicious anemia with 
achylia gastrica refractory to Fow¬ 
ler’s solution, symptomatic recovery 
occurred under a single intravenous 
injection of salvarsan. The patient 
gained 30 pounds in weight with a 
return of the blood-picture to nor¬ 
mal, but a positive Wassermann re¬ 
mained in the serum and negative in 
the spinal fluid. It is not, therefore, 
as an antiluetic that salvarsan acts. 
W. Egbert Robertson (N. Y. Med. 
Jour., July 4, 1914). 

It becomes a question whether neo- 
salvarsan might not be preferable to 
salvarsan in these cases, and whether 
either is preferable to arsenic. The 
writer used small doses of salvarsan 
and neosalvarsan intramuscularly in 
21 cases. The benefit was more 
prompt and the duration of the im¬ 
provement generally longer than 
when arsenic was given by the 
mouth. There also seemed to be a 
larger proportion of apparent cures. 
There was usually slight local dis¬ 
turbance and some fever. Morphine 
was occasionally necessary when the 
pain was very troublesome. Salvar¬ 


san seemed more effective than neo¬ 
salvarsan, but the latter caused less 
local reaction. Bramwell (Brit. Med. 
Jour., Mar. 6, 1915). 

The rate of salvarsan given intra¬ 
venously in pernicious anemia was 
shown by the writer’s experiences in 3 
very severe cases. In all of them the 
alministration of small doses of sal¬ 
varsan was followed by restoration 
of the blood-picture almost to nor¬ 
mal, but 2 of the cases recurred later, 
1 with a fatal outcome. Lampe 
(Med. Klinik, Nov. 19, 1916). 

An excess of Hydrochloric acid is not 
uncommonly found in the g’astric se¬ 
cretions. In such cases See recom¬ 
mends an almost exclusive diet of 
meat and other albuminous foods: 
raw meat to the extent of 10 to 12 
ounces daily. 

In the majority of cases there is 
deficiency of hydrochloric acid and 
pepsin, especially in advanced cases. 
Good effects have been obtained from 
large doses of hydrochloric acid and 
pepsin under these conditions. 

The great majority of cases of per¬ 
nicious anemia suffer from an ab¬ 
sence of hydrochloric acid and pep¬ 
sin in the gastric secretion, and this 
condition is further harmful in that 
the essential element for pancreatic 
secretion is produced only under the 
stimulus of the acid chyme passing 
over the duodenal mucosa. To cause 
an artificial digestion, pancreatic as 
well as gastric, hydrochloric acid and 
pepsin in much larger doses than are 
usually considered permissible prove 
effective. In a personal case, the pa¬ 
tient received 30 grains of pepsin 
and 105 minims of dilute hydrochloric 
acid three times a day, the latter he- 
ing given in 15-minim doses every 
ten minutes in albumin water to dis¬ 
guise the taste. The fact that the 
acid was given combined instead of 
free did not affect its action. The 
further treatment consisted in daily 
irrigations of the colon and a liberal 
mixed diet. It was shown from the 


ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 


623 


blood examination that the treatment 
had been followed by most satisfac¬ 
tory results. Julius Rudisch (Med. 
Rec., March 5, 1910). 

Croftan, of Chicago, found that 15 
drops of the strong hydrochloric acid 
after each meal procured notable im¬ 
provement in 14 cases, the symptoms 
of pernicious anemia disappearing 
while those of achylia persisted. The 
writer recommends Croftan’s treat¬ 
ment in all cases showing reduced 
gastric acidity. He gives 10 to 15 
drops of the acid in mucilage water 
a few minutes after each meal, the 
dose being repeated in 30 minutes. 
The mucilage water, which is em¬ 
ployed to prevent injury to the gas¬ 
tric mucosa by the acid, consists of 
1 ounce (30 Gm.) of pulverized acacia 
to 1 quart (1000 c.c.) of water. One- 
half glassful of the mucilage water 
is used to each dose of acid. He 
deems it important to regulate care¬ 
fully the dose, for if too little is 
given the patient will not reap the 
benefit of the treatment, while if too 
much is given he will not retain the 
remedy. J. A. Sealy (Lancet-Clinic, 
Feb. 15, 1913). 

The use of bone-marrow, intro¬ 
duced by ETaser, has given good re¬ 
sults in some cases and no results 
whatever in others. Freshly prepared 
each day with an equal quantity of 
glycerin, red marrow, 1 or 2 ounces 
daily, has seemed to give the best re¬ 
sults. It should be tried only where 
arsenic has failed. 

Transfusion of blood should never 
be omitted when improvement does 
not follow the administration of ar¬ 
senic. The best method is that'em- 
ployed by Brakenridge, of Edin¬ 
burgh. The blood is kept fluid by 
admixture with one-third part of its 
bulk of a 1 :20 (5 per cent.) solution 
of phosphate of soda in distilled water 
kept at blood heat. John Duncan, 
who performed the transfusions in 
Brakenridge’s cases, insists upon the 


necessity of slowness in operating. 
He regards thirty minutes as the 
minimum time that should be occu¬ 
pied in injecting 8 ounces of fluid. 

Series of 26 cases treated by trans¬ 
fusion at the Mayo Clinic. Forty- 
six transfusions were performed in 
the series, a single transfusion prov¬ 
ing sufficient in only 11 patients. 
Sixty-nine per cent, of the entire 
series received marked immediate 
benefit from the procedure. Among 
14 unfavorable cases deemed unsuit¬ 
able for splenectomy similar improve¬ 
ment was noted in 50 per cent. Up 
to the sixth decade, the age of the 
patient had no bearing on the results; 
of 5 patients between 60 and 70 but 
1 showed definite improvement. 
Patients with a history of remissions, 
even though ill for several years, 
seemed most benefited by transfusion. 
Those without remissions often failed 
to respond. Recent, acute cases were 
usually little influenced. Results fol¬ 
lowing transfusion from relatives 
were not superior to those in the 
cases of unrelated donors. But 1 
patient had a severe reaction; mild 
fever and a severe chill lasting 40 
minutes followed transfusions from 
the wife and from a friend; no bene¬ 
fit resulted. Eleven patients had mild 
fever for a day or 2. Such reactions 
did not prove necessarily indicative 
of benefit from the procedure. Gen¬ 
eral improvement usually paralleled 
that in the hemoglobin. Distressing 
numbness, burning, and tingling ot 
the hands and feet were relieved by 
the treatment. When no benefit fol¬ 
lows a transfusion, a different donor 
should be tried. A. Archibald (St. 
Paul Med. Jour., Feb., 1917). 

Massive transfusions of blood offer 
the greatest chance of improvement 
to sufferers from pernicious anemia, 
but any error in the technique may 
be followed by a fatal result. The 
procedure is one which should be at¬ 
tempted only by those who have had 
considerable experience in intraven¬ 
ous injections and are well acquainted 
with the physiological teachings 


624 


ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 


about clotting of blood. Even with 
perfectly matched bloods reactions 
may occur, but they may be pre¬ 
vented by the administration half an 
hour before the injection of Mso 
grain (0.0004 Gm.) of hyoscine 
methyl bromide along with % grain 
(0.01 Gm.) of morphine. O. Leyton 
(Pract., Mar. 1917). 

The writer observed 2 cases of per¬ 
nicious anemia in infants of 11 and 5 
months from private practice. He 
has previously published 2 personal 
cases, and found 56 cases in the 
literature. This includes 32 cases in 
which the anemia was traceable to 
the bothriocephalus or a tenia. Only 
2 cases are known of essential pro¬ 
gressive pernicious anemia in older 
children. The serum used was ob¬ 
tained by venesection of animals at 
the height of the regeneration of 
blood following a previous extensive 
withdrawal of blood. This hemato¬ 
poietic serum seems to have a de¬ 
cidedly favorable action on the com¬ 
position of the blood, when injected 
in cases of pernicious anemia. These 
infants were given daily subcutane¬ 
ous injections of 5 or 10 c.c. of the 
serum. The changes in the blood 
were from hemoglobin 20 per cent, 
and reds 658,875, to 53 per cent, and 
2,102,125 reds in 9 months, indicate 
the practical efficacy of this form of 
serotherapy. A. D’Espine (Revue 
Medicale de la Suisse Romande, Aug 
1918). 

Transfusion offers more for pro¬ 
gressive pernicious anemia than any 
other form of treatment. 

The theory of toxic hemolysis is 
accepted to explain the genesis of the 
disease. 

It is highly probable that trans¬ 
fusion of blood owes its beneficial 
effects to the stimulation of the anti- 
hemolytic properties of whole blood, 
although the possibility of its power 
to increase the functional activity of 
the bone marrow should also be 
recollected. 

In a case seen by the writer in con¬ 
sultation transfusion produced a 
prompt remission lasting seven 


months, after the patient was thought 
to be lost. A second transfusion was 
followed by a remission, though less 
promptly, and at the time of writing, 
more than one year after the first 
transfusion, the patient declared that 
he had not “felt sc well for 15 years.” 
The blood picture, as well as the 
general health, were greatly improved 
by both transfusions. J. M. Anders 
(Trans. Assoc. Amer. Phys.; Med. 
Rec., Sept. 6, 1919). 

Daily findings reported as to the 
blood and urobilinemia after trans¬ 
fusion of 900 c.c. of blood drawn into 
120 c.c of a 2 per cent, solution of 
sodium citrate in a man of 33 with 
pernicious anemia during his third 
attack. In 2 weeks the erythrocytes 
had increased from 850,000 to 3,118,- 
000; the hemoglobin from 19 to 66 
per cent.; the bile pigment in the 
blood serum had dropped from 45 to 
7, and the urobilin figure from 875 
(4500 the second day after the in¬ 
fusion) to 42. The improvement pro¬ 
gressed for a time, but the man re¬ 
turned about 4 months later in his 
fourth attack, the erythrocytes hav¬ 
ing dropped to 1,382,000 and the 
hemoglobin to 28 per cent. Scheel 
and Bang (Norsk Mag. f. Laegev- 
idensk.. Mar., 1920). 

Defibrinated blood has been used 
subcutaneously by Westphalen with 

success. 

Subcutaneous injections of normal 
saline solution every alternate day, 
and on the intervening saline ene- 
mata, with arsenic internally, have 
been recommended by McPhedran. 

Intestinal antiseptics have been rec¬ 
ommended. Hunter holds that the 
best intestinal antiseptic is betanaph- 
thol and salol, along with arsenic 
when that can be borne. I consider 
thymol entitled to the first position, a 
fact which seems to be more fully ap¬ 
preciated in Italy than elsewhere. In 
accordance with the view that perni¬ 
cious anemia is due to the absorption 


ANEMIA, PERNICIOUS PROGRESSIVE (HENRY). 


625 


from the intestine of substances for¬ 
eign to the healthy body, and de¬ 
structive to the red corpuscles, its 
treatment by intestinal antiseptics is 
certainly most rational. 

When the disease is due to the Anky- 
lostoma dnodcnalc, thymol, 2 to 3 
drams daily, is a very effective vermi¬ 
cide, according to Bozzolo. 

Two cases due to Bothriocephahts 
latiis, the infection being accompanied 
by the severest kind of anemia. In 
one patient the red corpuscles fell to 
780,000 and the hemoglobin to IS per 
cent. The second case was even 
more severe the red corpuscles fall- , 
ing to 660,000 and the hemoglobin to 
10 per cent. Hemorrhages were 
noted along the veins of the retina. 
The improvement in both cases after 
thymol treatment was marvelous, and 
in the second patient in thirteen days 
the number of red corpuscles trebled. 
A. Meyer (Med. News, April 8, 1905). 

Herter recommends frequent and 
thorough irrigation of the colon, since 
it is the chief thriving place of the 
anaerobic bacteria which cause the spe¬ 
cific putrefaction. Following this sug¬ 
gestion, Dittmar and Hollis were able 
to report a few months ago recovery in 
2 cases of pernicious anemia by irriga¬ 
tion of the colon which had resisted 
all other methods of treatment. 

In all cases of pernicious anemia, 
the stools should be examined to de¬ 
termine the presence of a Bacillus 
capsulatus aerogenes infection. If 
these bacteria are present in great 
quantities, then high irrigation, com¬ 
bined with arsenic internally, should 
be used; and if the patient fails to 
improve then the appendix offers the 
best route for thorough irrigation. 
Lucius E. Burch (Jour. Amer. Med. 
Assoc., March 13, 1909). 

When the Bacillus capsulatus acrog- 
enes or the percentage of anaerobic 
bacteria found in evacuations from 
bowels is large, then, after thorough 
trial at colonic irrigation and failure 


to improve the symptoms or to les¬ 
sen the percentage of bacteria, the 
operation of appendicostomy is war¬ 
ranted. J. A. Witherspoon (Southern 
Med. Jour., July, 1909). 

Cholesterin has been introduced 
into the therapy of pernicious anemia 
because of Ransom’s finding that it 
prevented the hemolytic effects of 
some substances, such as saponin and 
cobra poison. A 3 per cent, solution 
of cholesterin in oil is given in 100- 
Gm. (3% ounces) doses daily. It is 
apt, however, to disagree with the 
patient. 

Three cases of pernicious anemia 
and 1 of secondary anemia referable 
to nephritis in which cholesterin was 
used for therapeutic purposes, the 
aim being to counteract any hemoly¬ 
sins that might be active in a manner 
analogous to the action of cholesterin 
on cobra lecithide. Of the 3 cases, 
one patient remained unimproved, 
while in ’ the other two cholesterin 
was decidedly beneficial. The latter 
case was in a wretched condition, 
with intense dyspnea, ascites, pleural 
effusion, edema, and a red count of 
750,000 with 18 per cent, of hemo¬ 
globin. After a week the count had 
risen to 1,750,000 and the hemoglobin 
to 30 per cent., while the threatening 
symptoms had all disappeared. The 
improvement was thus quite remark¬ 
able, but after a few weeks no further 
gain was obtained and still later a re¬ 
lapse occurred which ended fatally. 
Reicher (Berl. klin. Woch., Nu. 41-42, 
1908). 

When cases prove refractory to ar¬ 
senic the writer found cholesterin 
efficient in daily doses of 1 to 2 Gm. 
(15 to 30 grains) administered in 
cachets or oily solution. M. Roch 
(N. Y. Med. Jour., Mar. 8, 1913). 

Glycerin has also been tried in para¬ 
sitic pernicious anemia, as a result of 
Tallqvist and Faust’s suggestion that 
glycerin might combine with the lipoid 
substance assumed to be responsible 


626 


ANEMIA, SECONDARY (DA COSTA AND JUMP). 


for the disintegration of the red cor¬ 
puscles and thus combine to form a 
harmless product. The special lipoid 
substance found in the anemia from 
intestinal parasites proved to be oleic 
acid, and this combines with glycerin 
to form triolein. 

In the first of 2 cases in which 
glycerin was tried, the result was 
very encouraging, and in the second 
administration of 3 tablespoonfuls of 
glycerin a day, with lemon juice, was 
followed in the course of two and a 
half months by an increase in the red 
corpuscles from 990,000 to 4,760,000, 
and of hemoglobin from 20 to 90 per 
cent. No other drugs were given 
except a little antipyrin and caffein 
for a day or so to combat a neuralgic 
headache. Vetlesen (Norsk Mag. f. 
Laeger, Oct, 1909). 

Operative treatment of pernicious 
anemia was introduced by Eppinger, 
of Vienna, splenectomy having first 
been performed by this surgeon in 
1913 on the sound plea that the red 
cells were chiefly destroyed in the 
spleen. As Thayer states, however, 
it seems a serious matter to expose 
the patient to the extra danger of so 
severe an operation, when, as is well 
known, some patients may live years 
without operative intervention. 

The mortality of splenectomy ap¬ 
pears to be about 11 per cent. The 
best results of splenectomy are said 
to be obtained in the treatment of 
hemolytic jaundice. Eliot and Kava- 
nel in 48 cases collected in 1915 re¬ 
ported only 2 deaths, a mortality of 
4.2 per cent. Krumbhaar in 1916 had 
collected 156 cases of pernicious ane¬ 
mia treated by splenectomy with 30 
deaths. The Mayo Clinic reported 
32 splenectomies for pernicious ane¬ 
mia up to April 1, 1916, with 3 deaths, 
or 9.7 per cent, mortality. Of the 
survivors, 22 or 78 per cent., showed 
continued improvement; of 16 fol¬ 
lowed up for 6 months, 11 continued 
to improve and 3 had relapses. From 


the experience of the Mayo Clinic it 
would seem that splenectomy should 
be considered where the patient is 
youthful and middle aged, where he 
shows good general resistance, where 
splenic enlargement is of moderate 
degree, and where there is evidence 
of hemolytic action. 

The treatment of pernicious anemia 
by splenectomy is still on trial and is 
apparently merely palliative. There 
is, however, reasonable hope for im¬ 
proved results. J. B. Deaver (Phila. 
Co. Med. Soc.; N. Y. Med. Jour., 
July 27, 1918). 

Among 50 cases of pernicious ane¬ 
mia treated by splenectomy more 
than 3 years before, the writers found 
that 10 patients (21.3 per cent.) of 
those who had recovered from the 
operation survived splenectomy 3 
years or longer. Five patients (10.6 
per cent.) had survived more than 
4E’ years. In addition to the imme¬ 
diate remission which occurred con¬ 
stantly following splenectomy, splen¬ 
ectomy prolonged life in at least 20 
per cent, of the cases. The patient 
shows a more marked immediate im¬ 
provement in the 'type of case in 
which there is evidence of active 
hemolysis. Splenectomy may be rec¬ 
ommended in pernicious anemia when, 
in view of all the circumstances, per¬ 
sonal as well as medical, the possi¬ 
bility of prolongation of life appeals 
to the family and patient. Occasion¬ 
ally it may be performed to bring 
about an immediate remission. Gif- 
fin and Szlapka (Jour. Amer. Med. 
Assoc., Jan. 29, 1921). 

Frederick P. Henry 

AND 

J. Norman Henry, 

Philadelphia. 

ANEMIA, SECONDARY, OR 
SYMPTOMATIC. —DEFINI¬ 
TION. —A deficiency either in the 
quantity or the quality of the blood, 
affecting the blood mass or the cellular 
and albuminous constituents. Genuine 
secondary anemia is essentially a symp- 


ANEMIA, SECONDARY (DA COSTA AND JUMP). 


627 


tomatic disorder, referable to obvious 
pathological conditions, which deplete 
the blood volume, diminish the number 
of erythrocytes, and reduce the amount 
of hemoglobin and albumin. 

When summed up all cases of ane¬ 
mia include very few of the so-called 
primary anemias and a great many 
forms of secondary anemia. The 
secondary or simple anemias, anal¬ 
yzed from the standpoint of cause, 
might be grouped under: 1, infec¬ 
tions; 2, those following hemorrhage, 
manifest or concealed; 3, those due 
to some form of intoxication, in 
these days new poisons are being en¬ 
countered, and cases, such as had 
been termed pernicious anemia, might 
be due to TNT poisoning; 4, para¬ 
sitic anemia;. 5, anemias that were 
expressive of some deep seated, per¬ 
haps overlooked, neoplasm. Alfred 
Stengel (Trans. Phila. Co. Med. Soc.; 
N. Y. Med. Jour., July 27, 1918). 

TYPES OF SECONDARY 
ANEMIA.—It is convenient to 
classify the simple secondary anemias 
into several clinical groups which 
relate directly to the predominant 
factor active in the individual case. 
While a classification of this sort 
must needs be imperfect, for fre¬ 
quently several factors are concerned 
in a single instance, it will serve to 
designate the important underlying 
condition of which the blood im¬ 
poverishment is symptomatic. The 
following groups are sufficient for the 
inclusion of all anemias of secondary 
origin. I, posthemorrhagic; II, infec¬ 
tious and toxic, and III, trophic. 

I. Posthemorrhagic anemias com¬ 
prise that varied class of cases directly 
traceable to bleeding, irrespective of 
its extent, duration, and character. 
In this group, therefore, are included 
the acute anemias due to loss of blood 
by trauma, operation, abortion, par¬ 


turition, epistaxis, hemoptysis, gastric 
and intestinal ulcer and neoplasm, 
hemorrhagic pancreatitis, and under 
the same heading are the grave ane¬ 
mias consecutive to the rupture of 
an aneurism, of a Fallopian tube, and 
of a large mass of varicose veins. 
The hemorrhagic diseases (purpura, 
hemophilia, scurvy), hemorrhoids, and 
uterine fibroids, all of which are cap¬ 
able of causing persistent, though per¬ 
haps moderate, loss of blood, may also 
excite a secondary anemia, perhaps of 
pronounced severity. 

Various authors have described 
certain differences which they deemed 
to be fundamental, but the experi¬ 
ments of the writer indicate that al¬ 
though there are minor differences, 
all the essential features of anemia 
produced by toxins can be produced 
by hemorrhage. Milne (Jour, Exper. 
Med., Sept., 1912). 

In a comprehensive study of blood 
transfusion in the treatment of severe 
posthemorrhagic anemia and the 
hemorrhagic diseases, the writer 
found that in acute and chronic post¬ 
hemorrhagic anemia, no other rem¬ 
edy would compare in efficiency with 
whole blood in producing hemato¬ 
poietic stimulation. In the acute 
variety (following trauma, labor, op¬ 
eration, or accidental cause, or as 
complication of ectopic pregnancy, 
gastric or duodenal ulcer, typhoid 
fever, etc.) a single large transfusion 
is indicated, while in the chronic type 
(that resulting from repeated small 
losses of blood) better results are ob¬ 
tained by giving serial transfusions of 
small or moderate amounts of blood. 
E. W. Peterson (Med. Rec., Apr. 15, 
1916). 

II. Infectious and toxic anemias 

develop chiefly as the result of hemo¬ 
lytic agencies, and are encountered in 
the specific infections, malignant dis¬ 
ease, intestinal helminthiasis; in poi¬ 
soning by certain so-called blood 


628 


ANEMIA, SECONDARY (DA COSTA AND JUMP). 


poisons—nitrobenzol, potassium chlo¬ 
rate, lead, mercury, arsenic, antimony; 
and in states of autointoxication— 
uremia, cholemia, pregnancy. Of the 
acute febrile infections that account 
for anemia of moderate intensity, 
enteric fever, sepsis, variola, erysipe¬ 
las, rheumatic fever, and scarlatina 
may be named as typical examples. 
The anemia excited by malignant 
neoplasms is attributable partly to 
the action of circulating tumor-toxins 
and partly to concomitant factors, 
such as hemorrhage, ulceration, and 
interference with nutrition, as in 
esophageal and gastric growths. The 
anemia of helminthiasis is due prin¬ 
cipally to the hemolytic action of 
poisonous substances elaborated by 
the worm, notably in the case of 
uncinariasis and bothriocephalus dis¬ 
ease, and to a less extent in persons 
harboring oxyurides, ascarides, and 
filariae. Helminthiasis anemia is also 
favored by the associated gastroin¬ 
testinal disorders, and, in uncinari¬ 
asis, the parasites suck blood from 
the intestinal vessels of the host and 
pour out an absorbable anticoagulant 
material which may act deleteriously 
upon the circulating blood-cells. The 
luetic virus materially damages the 
hemoglobin and erythrocytes, and 
syphilitics as a class are subject to a 
form of toxic anemia which as a rule 
attains its greatest development dur¬ 
ing the tertiary stage of the infection. 
In malarial fever it is probable that 
the presence of a circulating specific 
malarial toxin, produced by myriads 
of parasites, has much to do with 
provoking the attendant anemia, and 
it is certain that in this infection 
the blood must sufifer from the whole¬ 
sale destruction of parasitiferous 
erythrocytes. 


Report of experiments showing 
that vitiated air can cause anemia in 
human beings only when there is 
some predisposition of a toxic order 
to influence the blood-making organs. 
The bad air of prisons, workshops, etc., 
causes only pseudoanemia, i.e., pallor of 
the integument, but no changes in the 
blood. Krotkoff (Roussky Vratch, Jan. 
18, 1914). 

Aplastic anemia in young persons 
is the result of the exhaustion of 
function of a bone marrow congeni¬ 
tally defective in power of endurance, 
in older persons it is the result of some 
poison or poisons which, acting on the 
bone marrow, destroys its function and 
leads to death. A pathologic hemoly¬ 
sis as an essential part of this syndrome 
has not been shown. Rennie (Med. 
Jour, of Australia, June 14, 1919). 

In a case reported by the writer, 
exposure to the X-rays for about 15 
years was considered to be the cause 
of the anemia. It was of short dura¬ 
tion, the patient succumbing in about 
6 months, and symptoms were com¬ 
plained of only during the last 2 
months. The rapid diminution in the 
red and white corpuscles was very 
noticeable, the reds disappearing at 
the rate of, roughly, 250,000 per week, 
and the whites sinking to 840. The 
color index was never over 0.9. The 
differential count was remarkable; 
Polynuclears, 41 per cent; lympho¬ 
cytes, large, 54 per cent.; small, 4 
per cent.; eosinophiles and baso- 
philes, none. Larkins (Lancet, Apr. 
16, 1921). 

III. Trophic anemias, or those of 
nutritional origin, are met with com¬ 
monly in subjects that suffer from 
chronic malnutrition due to faults in 
the quantity and quality of their 
food, to defective absorption and 
assimilation, or to a combination of 
these two causes, and in many such 
instances deficient air and sunshine, 
lack of exercise, confining occupation, 
and unsanitary surroundings must 
likewise be reckoned with as contrib- 


ANEMIA, SECONDARY (DA COSTA AND JUMP). 


629 


uting elements. Drains upon the 
albumins of the system, as in habit¬ 
ual nephritis, persistent suppuration, 
prolonged lactation, and chronic dys¬ 
entery, ultimately provoke well-de¬ 
fined, stubborn anemia of the trophic 
type. 

Von Jaksch’s anemia belongs to the 
category of trophic anemias. In 1889 von 
Jaksch described a case of leucemia in a 
child of 14 months, and in the following 
year he reported 3 cases of enlarged 
spleen in children, a condition which he 
called anemia pseudoleucemica infantum. 
This was characterized by a diminution in 
the hemoglobin and in the number of red 
cells, marked persistent leucocytosis, 
sometimes glandular enlargement, slight 
enlargement of the liver, a marked en¬ 
largement of the spleen, which was out of 
all proportion to the size of the liver, and 
a tendency to recovery. The blood-pic¬ 
ture is characterized by a great diminu¬ 
tion in the red cells and the hemoglobin, 
and a persistent leucocytosis. Most of the 
patients show a definite 'tendency to re¬ 
cover. The abnormal blood-picture in 
those who lived might persist for a very 
long period of time. This form of ane¬ 
mia is frequently associated with rickets. 
The symptoms are those of anemia in 
general, pallor, edema, weakness, dyspnea, 
etc. a large liver, and a very large spleen, 
with a characteristic blood-picture. The 
onset is gradual and the patient is usu¬ 
ally brought in for treatment when a well 
marked enlargement of the spleen has 
developed. 

After tuberculosis, diphtheria and 
the eruptive diseases, Leishman’s 
anemia or leishmaniosis is the most 
prevalent disease in southern Italy. 
Families living in rural districts or 
having much to do with domestic 
animals are specially subject to it. 
Direct contagion can be incriminated 
in most of the cases, the parasite 
probably being transmitted by means 
of bedbugs. There is also much to 
sustain the view that dogs and dog 
fleas are responsible for its transmis¬ 
sion. Franchini has recently found 
the parasites in gnats. G. Caronia 


(Archiv f. Kinderheilk, Bd. lix, Nu. 
5-6, 1913). 

Aplastic anemia develops as hemor¬ 
rhagic purpura which continues a 
steadily progressive course until the 
patient succumbs to the anemia in 
the course of a few weeks or months. 
In the case of a woman of 33 the 
patient had contracted syphilis 14 
years before but was apparently in 
perfect health when given an addi¬ 
tional mild course of mercury and 
salvarsan. Eight days after its con¬ 
clusion the hemorrhagic purpura de¬ 
veloped and progressed to a fatal 
termination in 15 days. In this, as 
in all the cases on record, the small 
numbers or total absence of blood- 
platelets was a striking feature of the 
case. E. Frank (Berl. klin. Woch., 
Sept. 13, 1915). 

School Children’s. — The writer 
studied 42 cases of a form of anemia 
found in school children character¬ 
ized by eosinophilia. Various para¬ 
sites were always present in the 
feces. The degree of eosinophilia is 
uninfluenced by the kind of parasite 
present. He advises, therefore, that 
in all cases of anemia in school chil¬ 
dren the blood should be carefully 
examined for eosinophilia and the 
stools be searched for the ova of in¬ 
testinal worms. Scaroni (Gaz. degli 
Osped. e delle Clin., Jan. 7, 1917). 

PATHOLOGY.—The principal 
pathologic alterations incident to ane¬ 
mias of the secondary type relate to the 
composition of the circulating blood 
and to the histology of the bone-mar¬ 
row, of which the former changes are 
the more important, and, obviously, 
more readily available to the clinician. 
The blood changes vary within wide 
limits, depending upon the grade and 
the chronicity of the individual case; 
but in general it may be stated that 
they are of very moderate intensity in 
the average example of general symp¬ 
tomatic anemia. There is a more or 
less decided diminution in the number 


630 


ANEMIA, SECONDARY (DA COSTA AND JUMP). 


of erythrocytes (oligocythemia) , with a 
tolerably proportionate reduction in the 
percentage of hemoglobin (oligochro- 
memia), and, in severe cases, one ob¬ 
serves structural changes implicating 
the erythrocytes’ stroma and eventually 
leading to the production of corpuscular 
deformities of shape (poikilocytosis)^ 
and of size (megalocytosis; micro¬ 
cytosis). Not always, however, is the 
hemoglobin-erythrocyte reduction pro¬ 
portionate, for in some forms of sec¬ 
ondary anemia the hemoglobulin loss is 
greatly disproportionate to that of the 
cells, as, for example, in so-called 
“syphilitic chlorosis,” which, hemat- 
ologically, counterfeits maiden’s chlo¬ 
rosis; on the contrary, in other types 
the erythrocytes suffer chiefly, as in 
that variety of parasitic anemia pro¬ 
voked by the Bothriocephalus latus, 
which apes true pernicious anemia in 
every detail of the blood-picture. 
These facts call for great caution in 
attempting to diagnose a secondary 
anemia by the blood changes alone, 
without due regard for the discovery 
of some adequate causal factor to 
be correlated therewith. In active, 
severe cases of anemia young, nu¬ 
cleated erythrocytes (normoblasts) es¬ 
cape prematurely from the bone- 
marrow and appear in the circulating 
blood in limited numbers, and in the 
event of intense retrograde marrow 
changes an occasional nucleated cor¬ 
puscle of fetal type (megaloblast) also 
may be observed. With such evidences 
of high-grade blood deterioration one 
also meets with cells disfigured by 
atypical staining proclivities (polychro- 
matophilia) , and with cells whose proto¬ 
plasm is stippled with fine and coarse 
basic granules (granular basophilia), 
both of which abnormal findings 
point to a considerable degree of 


stroma degeneration, whereby the 
affected cells no longer react toward 
acid aniline dyes, as they do normally, 
but show a selective affinity for basic 
colors, by which the stroma of the 
healthy red corpuscle is never stained, 
when exposed to a mixture contain¬ 
ing both acid and basic dyes. The 
behavior of the leucocytes in second¬ 
ary anemias is most inconstant. In 
chronic cases, especially those due to 
trophic defects, and in certain of the 
slowly progressive toxic anemias the 
leucocyte count does not deviate 
from normal, or, if it shows any ap¬ 
preciable change, becomes subnormal 
(leucopenia) . In these leucopenic ane¬ 
mias it is also the rule to find a dis¬ 
proportionately high percentage of 
lymphocytes (relative lymphocytosis), 
these cells increasing in number chiefly 
at the expense of the polynuclear 
forms. 

The writer considers a high bili¬ 
rubin content of the blood serum as 
an instructive sign of abnormal 
hemolysis. That the spleen is the 
main seat of destruction of red cor¬ 
puscles has been confirmed anew by 
his and Daniels’ recent experimental 
research with injections of hemolytic 
serum into rabbits before and after 
splenectomy. The latter protected 
the animals against the hemolysis to 
a great extent. The hemoglobin re¬ 
leased from the corpuscles destroyed 
in the spleen is carried along the por¬ 
tal vein to the liver, where it is split 
up into bilirubin. L. S. Hannema 
(Nederlandsch Tijdsch. v. Genees- 
kunde, Nov. 3, 1917). 

Other anemic blood changes, of 
very minor importance, comprise in¬ 
creased rapidity of clotting and sub¬ 
normal specific gravity values. 

Anemia appearing in the face of 
active hemorrhage, of acute infectious 
processes, and of malignant disease is 
ordinarily attended by a leucocyte 


ANEMIA, SECONDARY (DA COSTA AND JUMP). 


631 


increase affecting mainly the poly¬ 
nuclear cells {polynuclear neutrophile 
leucocytosis), and in helminthetic dis¬ 
eases of recent origin there is a very 
constant increase in the percentage of . 
eosinophile cells {polynuclear eosino- 
phile leucocytosis). The presence of 
small numbers of immature polynuclear 
neutrophile cells {myelocytes) in the 
blood is frequently noted in many of 
the severer anemias of symptomatic 
character, irrespective of the presence 
or absence of a leucocytosis. 

The bone-marrow in a severe case 
of anemia undergoes a moderate de¬ 
gree of softening and acquires a some¬ 
what reddish hue, the attendant his¬ 
tological changes of this transforma¬ 
tion consisting of a hyperplasia of the 
lymphoid elements and a diminution 
in the number of fat-cells, which are 
replaced by marrow-cells or myelo¬ 
cytes charged with neutrophilic and 
eosinophilic granulations. Nucleated 
erythrocytes or erythroblasts, chiefly 
of the normoblastic type, are numer¬ 
ous when active powers of hemo- 
genesis persist. H. C. Bunting’s 
studies of the blood and bone-marrow 
in rabbits rendered anemic by the 
injection of hemolytic poisons has 
thrown a clear light upon the dif¬ 
ference between the marrow changes 
incident to anemias of different 
grades of development. This investi¬ 
gator showed that hemolytic anemia 
excited by saponin is associated with 
more or less effectual depletion of 
the marrow-centers wherein prolifera¬ 
tion of the blood-cells takes place, 
and with fragmentation and other 
degenerative changes in the other 
marrow-cells, the blood-picture be¬ 
traying this grave myeloid lesion 
virtually corresponding to that of 
true pernicious anemia in man. In 


contrast to these findings, posthemor¬ 
rhagic anemia, despite the presence 
of characteristic changes in the pe¬ 
ripheral blood, does not affect the in¬ 
tegrity of erythrogenic and leucogenic 
centers of the marrow. Furthermore, 
it would appear that in some in¬ 
stances the proliferating centers of 
the marrow become quite replaced 
by scar tissue, in which event the 
hematopoietic function, now impos¬ 
sible for the crippled marrow to 
carry on, is undertaken by the spleen. 

The visceral changes to be noted in 
cases of chronic secondary anemia in¬ 
clude granular degeneration of the 
liver, kidney, and heart, and, in some 
instances, fatty changes in these 
organs. These lesions depend more 
upon concomitant disturbances, such 
as toxemia and nutritional faults, 
than upon the effect of the anemia 
per se, and it seems within the bounds 
of reason to assume that they arise 
in part from an undue visceral activ¬ 
ity excited by the organism’s attempt 
to maintain a normal process of 
oxidation. 

The liver, the spleen, and fre¬ 
quently the lymph-nodes assume a 
fetal type in grave or pernicious ane¬ 
mias as far as their cellular charac¬ 
ter is concerned. Erythroblastic cells 
and newly formed leucocytes appear 
in them, while the blood-making or¬ 
gan of the adult, the bone-marrow, 
shows likewise a picture of greatly 
increased activity. The writer, to¬ 
gether with Heinecke, has interpreted 
these phenomena as reparative in 
nature in opposition to another con¬ 
ception of the findings which seeks 
to interpret them as the primary re¬ 
sult of some unknown harmful agent. 
Von Domarus has greatly strength¬ 
ened the standpoint maintained by 
the writer by producing experimental 
anemias in animals and showing that 
the changes in the blood-making or- 


632 


ANEMIA, SECONDARY (DA COSTA AND JUMP). 


gans of intrauterine as well as of 
extrauterine life were similar in these 
animals to those observed in patients 
with pernicious anemia. Meyer 
(Munch, med. Woch., June 2, 1908). 

SYMPTOMATOLOGY. — Pallor, 
the suggestive hallmark of all ane¬ 
mias, is usually well marked in the 
secondary type of this affection, and 
the subject’s skin, mucosa, and nails 
may become so blanched as to ap¬ 
pear almost colorless. In other in¬ 
stances, the loss of color is much 
more moderate, and in still others 
the actual pallor is more or less ob¬ 
scured by a yellowish or muddy or 
icteroid staining of the integument. 
In passing, it may be remarked that 
pallor of itself does not justify a 
diagnosis of anemia, for many persons 
with unnaturally pale faces have a 
perfectly normal blood-picture, in 
view of which the blood examination 
must invariably be the court of final 
appeal. 

Aside from pallor, the most con¬ 
spicuous symptom groups in anemia 
are attributable to disturbances of 
the cardiovascular, the gastrointesti¬ 
nal, and the nervous systems. Of the 
circulatory symptoms, dyspnea, car¬ 
diac palpitation, and dropsical swell¬ 
ing of the ankles and legs are likely 
to prove sources of great distress to 
the patient, while the discovery of 
hemic murmurs at the base of the 
heart and of a venous hum at the root 
of the neck affords findings of the 
utmost pertinence. These anemic 
murmurs, generally situated at or 
near the pulmonic orifice, are almost 
invariably systolic in time and re¬ 
stricted to the precordial area or to 
its immediate vicinity. They are 
sometimes associated with a percepti¬ 
ble increase in the size of the cardiac 


outline, indicative of dilatation of the 
heart from defective myocardial nu¬ 
trition, overstrain, and, exceptionally, 
fatty degeneration. 

The distinct positive venous pulse 
observed in endocarditis is not an un¬ 
common symptom of anemia and is 
due to a relative muscular insuffi¬ 
ciency of the tricuspid orifice. The 
cause is the same as that of the 
mitral insufficiency so common in 
chlorosis. In order to make sure of 
the functional character of the con¬ 
dition it is important to bear in mind 
that a relative tricuspid insufficiency 
in anemia develops at the same time 
as the mitral insufficiency, while in 
endocarditis the tricuspid lesion usu¬ 
ally develops long after the mitral. 
Besides, disturbances of compensa¬ 
tion are usually absent. Von Leube 
(Zeit. f. klin. Med., Bd. Ivii, Nu. 3-4, 
1905). 

The foregoing symptoms, which 
are prominent only in severe anemias, 
promptly vanish as the normal compo¬ 
sition of the blood is regained, and 
frequently in such cases the pulse is 
inordinately rapid, of low tension, and 
subject to arrhythmic disturbances, 
while occasionally the abrupt, jerky 
beat of the Corrigan pulse is super¬ 
ficially imitated. 

Murmurs are audible inside the skull 
in anemia from any cause and grow 
less and less audible as the blood- 
supply returns to normal. In about 
50 patients the murmurs were often 
distinct in hemorrhagic gastric ulcer 
or cancer, in pernicious anemia and 
with lesions localized in the skull. 
They were more pronounced with 
abnormally low hemoglobin content 
than with low corpuscle count. H. 
Koster (Zentralbl. f. innere Med., 
Nov. 15, 1913). 

Of the symptoms referable to the 
gastrointestinal tract, anorexia, pyrosis, 
abdominal distention, sensitiveness, and 
unrest, nausea, and constipation may 


ANEMIA, SECONDARY (DA COSTA AND JUMP). 


633 


attract attention. In the average case 
of secondary anemia the motor powers 
of the stomach are unaltered, and the 
secretion of hydrochloric acid remains 
normal or is even increased. On the 
other hand, there is a decided tendency 
toward weakening the intestinal motor 
function, although the juices of the gut 
flow naturally (Boas, v. Noorden). 

Ulcers in the throat may be due to 
anemia or lowered vitality. The 
writer has seen 3 cases; all in young 
women. The ulcer is round, small, 
with scanty secretion. There was no 
history of either tuberculosis or 
syphilis and no swelling of the 
glands. Pohly (N. Y. Med. Jour., 
Aug. 27, 1910). 

The anemic vomiting in anemic 
girls is apt to be mistaken for gas¬ 
tric ulcer. The symptoms are pain 
in the epigastrium and vomiting ex¬ 
cited by almost everything that is 
placed in the stomach. Its mucous 
membrane is so hyperesthetic that 
whatever touches it causes pain and 
vomiting. This is often associated 
with pain and tenderness of the skin 
and muscles under the left breast, 
though there is nothing the matter 
with these structures. Whereas in 
ulcer solid food gives more pain than 
liquid, in anemic vomiting the pain 
and vomiting have not a constant re¬ 
lation to meals; they may have some 
of their worst attacks apart from 
food altogether. Sudden exertion, or 
being tired out, will bring on the 
same pain. Beddard (Pract., Mar., 
1912). 

Of the various nervous disturbances, 
headache, vertigo, syncope, insomnia, 
phosphenes, muscae volitantes, and tin¬ 
nitus aurium are familiar examples. 
Moderate, irregular fever is occasion¬ 
ally observed as a consequence of nerv¬ 
ous factors and as a sign of septic 
processes. Most anemics, particularly 
those of chronic character, complain of 
unnatural fatigue, both mental and 


muscular, and in severe cases the pa¬ 
tient may be incapable of sustained in¬ 
tellectual effort, exhibits curious mental 
caprices and irritability, and develops a 
myasthenia amounting almost to com¬ 
plete debility. 

Six cases of anemia of the central 
nervous system resulting in sclerosis 
of the cord. The onset of the disease 
is gradual. The symptoms are very 
variable as are the changes in the 
spinal cord. Sometimes the poste¬ 
rior columns are involved; sometimes 
the lateral tracts are added; again, 
there is a diffuse sclerosis of the en¬ 
tire cord. Paresthesia and ataxia 
may persist for years with few 
changes in the cord, or the intensity 
of the alterations may be much 
greater than the clinical symptoms. 
The mental state may be dull and 
inattentive, and there may be various 
muscular palsies of eye muscles or 
face. Leopold (Med. Rec., Mar. 5, 
1910). 

The blood-picture of secondary 
anemia is in no wise distinctive, as 
already pointed out in the remarks 
on the pathology of this affection. 
Usually there is a moderate and 
roughly parallel loss of hemoglobin 
and erythrocytes, the former being 
•diminished approximately 45 per 
cent, and the latter 30 per cent, below 
the normal standard, in the case of 
average severity. The stained film 
generally shows nothing more than 
simple pallor of the erythrocytes 
with, perhaps, a few misshapen cells 
and some tendency toward irregu¬ 
larity in their diameter measure¬ 
ments. Normoblasts and erythrocytes 
with stroma degeneration are met 
with only in anemias of great inten¬ 
sity, characterized by excessive de¬ 
struction of the cells, and under such 
conditions an occasional megaloblast, 
indicating a fetal reversion of the 
marrow, may enter the blood-stream. 


634 


ANEMIA, SECONDARY (DA COSTA AND JUMP). 


Leucocytosis, developing under the 
circumstances referred to in a pre¬ 
ceding paragraph, means stimulation 
of the marrow’s functional activity, 
the exhibition of which is regulated 
largely by the nature of the excit¬ 
ing cause and by the individual pe¬ 
culiarities dominant in the case under 
consideration. The coagulation-time 
(hematopexis) of the blood is short¬ 
ened in close relation with the degree 
of existing anemia. 

The blood lipoid values in anemia 
were found by the writers to be nor¬ 
mal, or nearly so, as long as the per¬ 
centage of blood corpuscles remained 
above half the normal value. When 
the percentage was below this level 
abnormalities appeared which, in the 
order of their magnitude and also of 
the frequency of their occurrence 
were (1) high fat in the plasma, (2) 
low cholesterol in the plasma and oc¬ 
casionally in the corpuscles, and (3) 
low lecithin in the plasma. The 
lipoid composition of the corpuscles 
was found to be normal in prac¬ 
tically every case. Bloor and Mac- 
Pherson (Jour. Biol. Chemistry, July, 
1917). 

DIAGNOSIS. —The diagnosis of 
secondary anemia invariably must be 
based upon a suggestive blood picture 
plus the discovery of some factor 
responsible therefor. Given a blood 
poor in hemoglobin and erythrocytes 
in an individual suffering, for instance, 
with sepsis or gastric cancer or rheu¬ 
matic fever, the diagnosis can tax no 
one’s intelligence. But given an ob¬ 
scure etiologk factor in an anemic 
person, one must carefully interrogate 
through a long list of potential causes 
of blood impoverishment in order to 
detect a satisfactory cause. The dif¬ 
ferential diagnosis of secondary ane¬ 
mia includes the consideration of 
pseudoanemia, chlorosis, pernicious 


anemia, splenic anemia, leukemia, 
chloroma, and Hodgkin’s disease. 

Pseudoanemia versus true anemia is 
a differentiation constantly to be 
borne in mind in examining a patient 
for the first time. Spurious anemia, 
which, of course, shows a normal 
blood report, is characterized by un¬ 
natural pallor of the skin and mucous 
surfaces, probably of hereditary origin 
and explainable on the grounds of a 
deficiency of skin pigment and abnor¬ 
mal constriction of the superficial 
capillary network. Apart from pallor, 
the affection is quite symptomless. 
In this connection may be mentioned 
an angiospastic type of pseudoanemia, 
recognized by the abrupt appearance 
of attacks of transient grayish pallor 
induced by emotion, fatigue, exposure 
to cold, and similar vasomotor stimuli. 

Chlorosis, though its blood picture 
may be precisely counterfeited by 
certain forms of secondary anemia 
(such as Chlorosis, q.v.), is readily dis¬ 
tinguished from the latter by its oc¬ 
currence exclusively in girls and in 
young women who exhibit, with pass¬ 
able fidelity, a varied train of un¬ 
mistakable chlorotic stigmata—green¬ 
ish pallor, menstrual disturbances, 
perverted appetite, indigestion, con¬ 
stipation, slight enlargement of the 
thyroid gland, and many symptoms 
referable to functional neuroses. 

Pernicious anemia in its typical form 
gives rise to three most pertinent 
blood changes: extreme oligocythe¬ 
mia combined with a disproportion¬ 
ately slighter oligochromemia; the 
presence of numerous erythroblasts, 
of which cells those of a megaloblastic 
type predominate; and many de¬ 
formed and otherwise degenerate 
erythrocytes, notably megalocytes 
and basophilic corpuscles. The first 


ANEMIA, SECONDARY (DA COSTA AND JUMP). 


635 


detail of this blood-picture means 
that the hemoglobin content of the 
erythrocytes {color index) is unnat¬ 
urally high; the second indicates 
active compensatory hemogenesis and 
fetal reversion of the bone-marrow, 
and the last points to the manufac¬ 
ture by the marrow of numerous 
faultily formed, functionless erythro¬ 
cytes, of little or no use as oxygen 
carriers. Leucopenia, relative lym¬ 
phocytosis, and a moderate degree of 
myelocytosis are among the other 
hematological features of this disease. 
In addition to these findings, it must 
be recalled that true pernicious ane¬ 
mia arises insidiously, is entirely un¬ 
connected with any tangible causal 
factor, and invariably progresses 
steadily, perhaps with temporary 
periods of remission, to a fatal ter¬ 
mination. An aplastic type of per¬ 
nicious anemia has been described, in 
which, owing to extraordinary atro¬ 
phy of the bone-marrow, there arises 
an intense oligocythemia and oligo- 
chromemia with but trifling evidence 
of structural degeneration and nuclea- 
tion of the red corpuscles. In at¬ 
tempting the antemortem differentia¬ 
tion of aplastic anemia and anemia of 
the symptomatic variety (which at¬ 
tempt must needs frequently be con¬ 
jectural), attention should be paid 
especially to these hematological pe¬ 
culiarities of the first-named disease: 
relatively low color index; absence 
of erythroblasts of both types— 
normoblasts and megaloblasts; scar¬ 
city of cells showing stroma defects 
and anomalies of shape and size, and 
extreme lymphocytic leucopenia. It 
is also helpful to remember that 
aplastic anemia is prone to affect 
young women, is commonly asso¬ 
ciated with severe hemorrhagic phe¬ 


nomena, and, arising from no apparent 
cause, pursues a fatal course of short 
duration, unbroken by periods of 
remission. 

Splenic anemia, a rare and somewhat 
questionable clinical entity, causes a 
blood deterioration in no wise different 
from that accompanying an ordinary 
symptomatic anemia with leucopenia. 
But in splenic anemia there is an idio¬ 
pathic splenomegaly without enlarge¬ 
ment of the lymphatic glands, and, in 
the later stages of the disease, biliary 
hepatic cirrhosis, jaundice, and ascites 
supervene, to complete the symptom 
group sometimes spoken of as Banti’s 
disease. Disturbances due to severe 
anemia and to the pressure of an enor¬ 
mous spleen are generally conspicuous, 
and the disease is likely to develop 
insidiously, drags along for several 
years from bad to worse, and eventually 
kills. 

Leukemia is easily distinguished from 
secondary anemia by means of its dis¬ 
tinctive blood picture, as well as by 
certain objective symptoms. In the 
myelogenous form the combination of 
a high leucocyte count and excessive 
numbers of myelocytes (myelemia) is 
conclusive, and in such cases the spleen 
is generally enormous; in the lymphatic 
variety the detection of a high absolute 
and relative lymphocytosis (lymphemia) 
is equally convincing, and here it is the 
rule to find great hyperplasia of the 
lymphatic glands. 

Chloroma may account for an anemia 
identical with that of the secondary 
type, and it may also produce a blood 
picture closely comparable to that of 
lymphatic leukemia. In the former 
instance the low hemoglobin and eryth¬ 
rocyte values are accompanied by a 
relative increase in the number of 
lymphocytes, though the total leucocyte 


636 


ANEMIA, SECONDARY (DA COSTA AND JUMP). 


count does not exceed normal, while 
in the latter the blood shows great 
anemia with decided lymphemia. This 
being the case, one must recognize 
chloroma not by any distinctive blood 
formula, but by the chloromatous 
symptom-complex, made up of exoph¬ 
thalmos, deafness, severe orbital pain, 
elastic swellings in the orbital and tem¬ 
poral regions, and the formation of 
metastatic “green tumors” in the peri¬ 
osteal structures. 

In Hodgkin*s disease, which in time 
gives rise to high-grade secondary 
anemia, the existence of a progressive 
glandular hyperplasia in the neck, 
axilla, and groin is conclusive evidence, 
apart from the presence of pressure 
symptoms, irregular fever, cutaneous 
bronzing, asthenia, and extraordinary 
emaciation, which together spell this 
malignant affection. 

PROGNOSIS.—It is scarcely nec¬ 
essary to state that the prognosis in a 
given case of secondary anemia must 
depend upon the circumstances prevail¬ 
ing in the instance in question, the 
character, duration, and curability of 
the primary lesion being the decisive 
determining points of the forecast. 
The outlook in gastric cancer, for ex¬ 
ample, is very different from that in 
simple inanition or in one of the milder 
infectious diseases. On the whole, 
secondary anemia is a symptom that is 
promptly amenable to intelligent treat¬ 
ment, in strong contrast to which fact 
is the utter hopelessness of accomplish¬ 
ing a permanent cure in those deadly 
primary diseases of the blood, perni¬ 
cious anemia and the leukemias. 

TREATMENT.—Iron and arsenic, 
nutritious food, and correct hygiene 
will cure secondary anemia—provided 
that the essential cause of this symptom 
be removed. It is just as important to 


attend to a mass of bleeding piles or to 
treat an albuminuria in an anemic per¬ 
son as it is to prescribe hematinics, and, 
by the same token, it is equally impor¬ 
tant to outline a regimen in which an 
out-of-door life, ample sleep, and ra¬ 
tional personal hygiene are items of 
strict observance. 

The percentage of hemoglobin in in¬ 
fancy is below 55 at birth and not rising 
above 70 during the period properly 
so-called of infancy. The number of 
red corpuscles varies between 5,500,000 
and 6,000,000. This low hemoglobin per¬ 
centage is presumably due to an insuffi¬ 
cient supply of iron in its food and the 
lack of sufficient reserve of iron in the 
liver at birth. It is probable that true 
chlorosis never occurs in infants as a 
disease, but it is a fact that the chlorotic 
type of blood is very common at this 
age. Iron is, therefore, specially indi¬ 
cated, but it is difficult to get infants 
to take iron by the mouth, and it is very 
liable, moreover, to disturb the diges¬ 
tion. It is desirable, therefore, to give 
it some other way, and infants take it 
subcutaneously without injury. A very 
serviceable form for subcutaneous use 
is the aqueous solution of the citrate. 
This can be put up in pearls, each one 
containing a single dose, in which form 
it remains sterile indefinitely. It is ab¬ 
solutely non-irritating, and never causes 
abscess or induration if properly given, 
though it is somewhat painful. A glass 
syringe with an asbestos packing, which 
can be sterilized, and platinum needle 
that will not corrode with the iron. The 
average dose during infancy is three- 
quarters of a grain every other day. 
He has used this treatment in a number 
of cases in different types of anemia 
and with pretty satisfactory results, even 
in the severe cases. In the mild cases 
the improvement was very rapid, and the 
writer’s experience leads him to recom¬ 
mend the use of iron in this way. The 
results are more marked and more 
quickly obtained than by oral adminis¬ 
tration, and it is much less liable to dis¬ 
turb digestion. It is especially indicated 
in severe cases of secondary anemia 


ANEMIA, SECONDARY (DA COSTA AND JUMP). 


637 


with digestive disorder and in those 
of a sclerotic type. J. L. Morse 
(Jour. Amer. Med. Assoc., July, 
1910). 

A chlorotic type of anemia is ob¬ 
served in infants, in which there are 
pallor, digestive, circulatory, and 
nervous symptoms and a marked loss 
of hemoglobin, with a normal num¬ 
ber of red cells. The internal organs 
are normal; there are anemic mur¬ 
murs in the heart and vessels of the 
neck. The child is apathetic, quiet, 
has enlarged glands and sleeps 
poorly. This condition results when 
only milk is used, or when it is 
continued too long. The treatment 
is improved diet, and iron is ad¬ 
ministered in large doses. M. de 
Biehler (Arch, de Med. des Enf., 
Mar., 1913). 

A study of the action of iron in 
anemia led the writer to conclude 
that iron in proper doses elicits in a 
few days a stormy reaction in the 
bone marrow, which throws quanti¬ 
ties of young elements into the blood. 
In 10 cases of anemia with gastric 
ulcer, no benefit was evident under 
iron until large doses were given, and 
then the hemoglobin ran up rapidly 
from 37 to 82 and then to 100 per 
cent., and the reds to 5,024,000. Nageli 
(Schweizer. med. Woch., July 29, 
1920). 

The form of iron to be administered, 
it is almost needless to state, should be 
readily absorbable, and unlikely either 
to upset digestion or to constipate. The 
carbonate of iron, in the pill suggested 
by Blaud, meets these requirements as 
well as any other preparation, and has 
the prestige of a long and dependable 
clinical usage. Excessive dosage is to 
be avoided, since the use of 6 or 8 
grains a day will accomplish just as 
satisfactory results as a much larger 
amount, and will not tend to disturb the 
stomach or to constipate. Ferratin is a 
meritorious chalybeate, and is, if any¬ 
thing, even less astringent than Blaud’s 


pill. Of the other iron preparations 
sometimes chosen for the same reason, 
the phosphate, lactate, and citrate all 
enjoy considerable vogue. 

The headache of anemia is due 
chiefly to the deficiency of hemo¬ 
globin, and consequent tendency to 
edema, with the simultaneous starv¬ 
ing of the meninges. It is usually 
frontal, but may be vertical. In cer¬ 
tain individuals of lymphatic type, 
subject to anemia, chilblains, and 
cold extremities, there may be a de¬ 
ficiency of calcium salts in the blood, 
and the administration of the calcium 
salts may be of great service in re¬ 
lieving the headaches of such pa¬ 
tients. The lactate should be given 
in doses of 15 to 20 grains, three 
times a day. The headaches of the 
morning after copious libations have 
been ascribed to a lack of calcium 
salts in the blood, these having been 
precipitated by the organic acids con¬ 
tained in the wine. 

This headache may be very quickly 
removed by a dose of 20 to 30 grains 
of calcium lactate shaken up with a 
little water. Wilfrid Harris (Prac¬ 
titioner, July, 1906). 

There has been distinct progress in 
the treatment of anemia. The first of 
these is the method of direct trans¬ 
fusion introduced by Crile, whose ex¬ 
periments and results the author con¬ 
siders a brilliant illustration of the 
value of vivisection to humanity. The 
second is the use of colonic irriga¬ 
tions in pernicious anemia, as recom¬ 
mended by Herter, and successfully 
employed by Dittmar and Hollis. 
Herter’s discovery that special putre¬ 
factive processes in the intestines are 
due to the prevalence of anaerobic 
bacteria, particularly the Bacillus 
capsulatus aerogenes, and the paral¬ 
lelism of their presence with the 
symptoms of the disease suggested 
this treatment by injections, which 
the writer considers a valuable thera¬ 
peutic advance. The third point 
touched on in his paper is the estab¬ 
lishment of the clinical value of in¬ 
organic iron in the treatment of ane- 


ANEMIA, SECONDARY (DA COSTA AND JUMP). 


mia. Ingested iron, like the carbo¬ 
hydrates, is converted into inter¬ 
mediate organic compounds and en¬ 
ters into the reserve iron stored up 
in the body, which is normally in 
excess of the needs of the system. 
S. J. Meltzer (Jour. Amer. Med. 
Assoc., Aug. 24, 1907). 

Employing the hemoglobin con¬ 
tents as an index of the degree of 
secondary anemia, as well as an 
actual erythrocyte count, the writers 
found that the hypodermic use of the 
citrate of iron in the secondary ane¬ 
mia of tuberculosis permitted them 
to control the anemia with almost 
mathematical precision, and that it 
actually in no single instance failed 
to improve the quality of the blood 
to at least some degree in the 256 
cases in which they had employed it. 
Over 70 per cent, of these cases were 
in the advanced and far advanced 
classes, in which the anemia is a 
commonly manifested phenomenon. 
The measure was uniformly success¬ 
ful in raising the hemoglobin stand¬ 
ard to normal in all cases in which 
the patient might be considered to be 
doing well, or in which the status 
quo was seemingly maintained. 

It is not necessary to use a larger 
dose of citrate of iron than 0.05 Gm. 
Others who have used larger doses 
have observed sudden vomiting to 
follow its administration. The tech¬ 
nique of the method is to employ the 
ordinary hypodermic syringe and 
needle, selecting the buttock as the 
least inconvenient site of injection, 
and giving an injection daily until the 
result is obtained. E. S. Bullock and 
L. S. Peters (Jour. Amer. Med. 
Assoc., Oct. 28, 1911). 

The writer employed numerous 
proportions of iron for many years, 
but in the majority of cases, the re¬ 
sults obtained were less favorable 
than those given by the use of other 
remedies. Foods rich in iron, that is 
available through digestion, are pref¬ 
erable. Whenever the cause of the 
anemia present can be ascertained 
the treatment is governed by such 
data. In those cases not the result 


of advancing cardiac, renal, hepatic 
disease, or carcinoma, excellent re¬ 
sults follow the use of readily 
digested foods, meat juices; and 
special attention to the gastric intes¬ 
tinal tract. The administration of 
red bone marrow showed in 60 cases 
of anemia that the red blood cor¬ 
puscles, and the hemoglobin were 
more rapidly increased by this 
method, together with the fact that 
the patients were always fed liberally 
of green fruit and vegetables, than 
by any other. Napoleon Boston 
(Buffalo Med. Jour., June, 1917). 

Arsenic is of indispensable value as 
an adjunct to iron in dealing with 
anemia, particularly those forms dis¬ 
tinguished by relatively excessive oligo¬ 
cythemia, as in those severe instances 
consequent to infectious and malignant 
processes. The time-honored Fowler’s 
solution answers well in the majority of 
cases, but where an idiosyncrasy exists 
toward this preparation, as it frequently 
does, or where it is imperative to 
stimulate hemogenesis very rapidly, 
atoxyl (sodium anilarsenate) will prove 
the better form of arsenic. It should 
always be given hypodermically, in 
doses of from grain to 2 grains, on 
alternate days, until the patient has 
received about 20 grains, after which 
the drug is discontinued for a week, 
and then readministered according to 
the plan originally followed. Given in 
this manner, one need not fear that 
lamentable complication, optic neuritis, 
which has been produced by the ill- 
advised use of atoxyl. Or arsacetin 
(‘sodium acetyl arsanilate) may be used, 
in the same dose and by the same 
method advised for atoxyl, if it is 
thought best to employ an even less 
toxic preparation of arsenic. While 
useful, manganese, phosphorus, red 
bone-marrow, hemoglobin, oxygen, and 
the cacodylates are in no sense adequate 


ANEMIA, SECONDARY (DA COSTA AND JUMP). 


639 


substitutes for iron and arsenic in the 
treatment of anemic conditions. 

Hypodermic medication with iron and 
arsenic, together with strychnine and 
the hypophosphites, offers a prompt 
and powerful reconstructive adjunct 
to the pure air, good food, and sen¬ 
sible hygiene that are essentials in 
pretuberculous conditions. The green 
ammoniated iron citrate can be intro¬ 
duced into the system, without dan¬ 
ger, in doses of from to grains, 
while sodium arsenate is given in 
doses of from %o to Yso grain. The 
injections of solutions of these drugs 
are given deeply into the muscles of 
the buttocks or back. Only slight 
pain attends the procedure, 'and a 
general feeling of well-being follows 
the treatment. A full dose of the 
iron within five minutes causes a 
feeling of tension in the head, ting¬ 
ling sensations, and a flushing of the 
face. Doses larger than 1^2 grains 
may cause nausea or vomiting. B. R. 
Shurly (Jour. Amer. Med. Assoc., 
June 16, 1907). 

Sufficient is known to justify more 
than a suspicion that William Hunter 
was correct in believing that perni¬ 
cious or infective anemia should be 
laid at the door of mouth infection. 
The writer’s own experience tends to 
confirm this belief, particularly in 2 
recent cases of pernicious anemia. 
In 1 patient rigid examination failed 
to reveal any focus of infection save 
the mouth, which showed a bad glos¬ 
sitis and pyorrheal abscesses about 
all the few remaining teeth. After 
the administration of 52(X) c.c. (5j4 
quarts) of blood by citrate trans¬ 
fusion at intervals, the use of salvar- 
san intravenously, the administration 
of hydrochloric acid and good food 
and rest, only very temporary im¬ 
provement resulted. When all of 
the infected teeth were removed, the 
patient made such rapid and marked 
improvement that he had now re¬ 
sumed a laborious occupation with 
the appearance of health and a blood 
exhibit approximating the normal. 
M. L. Graves (Trans. So. Med. 


Assoc.; N. Y. Med. Jour., Jan. 12, 
1918). 

The anemic subject should eat 
plentifully of nutritious, and, it must 
be insisted, palatable, food—red 
meats, strong broths, eggs, butter, 
cream, fruits, and ferruginous vege¬ 
tables like spinach, asparagus, lentils, 
and cauliflower. If the appetite flags 
it may be advisable to whip it up with 
a glass of stout or of mild claret at 
mealtime, or by the use of the bitter 
tonics, the amount of food at the 
same time being intelligently re¬ 
stricted. Indigestion, if not fore¬ 
stalled by a rational dietary, must be 
combated by such useful remedies 
as pepsin and hydrochloric acid, pan- 
creatin and diastase, pawpaw, char¬ 
coal, and bismuth. It is most neces¬ 
sary for the patient to have a free 
bowel movement each day, to insure 
which, if other measures fail, it is 
good practice to resort to cascara 
sagrada, phenolphthalein, singly or 
combined with aloin, strychnine, and 
belladonna, and supplemented by a 
dram or two of Carlsbad salts dis¬ 
solved in a tumblerful of hot water, to 
be slowly sipped each morning di¬ 
rectly on arising. Intestinal fermen¬ 
tation, the bane of so many anemics, 
is best treated dietetically (eggs are 
notorious offenders), by intestinal 
irrigation, by the administration of 
cultures of the lactic acid bacillus, and 
by the use of B-naphthol, salol, bis¬ 
muth salicylate, phenol, and similar 
antifermentative drugs. In patients 
with troublesome nervous symptoms 
strontium bromide and the valerian¬ 
ates of iron, quinine, and zinc are 
helpful adjuncts to the therapeusis 
suggested above. 

In anemia due to autointoxication 
from the gastrointestinal tract, as 


640 


ANEMIA, SECONDARY (DA COSTA AND JUMP). 


often occurs in chlorosis: 1. Favor 
gastric functions by proper diet 2. 
Secure regular bowel movements by 
laxatives. 3. Begin the use of iron, 
giving following pill: Subcarbonate 
of iron, 0.10 Gm. (1^ grains) ; pow¬ 
dered aloes, 0.02 Gm. grain); 

extract of rhubarb, 0.05 Gm. (% 
grain); 2 pills before meals. Huchard 
and Fiessinger (Revue de therap., 
March 15, 1910). 

The writer advises the daily use of 
green vegetables, not only for the 
anemic and dyspeptic, but for the 
healthy as well. Chlorophyll has 
been given as such to the anemic, but 
doubtless cannot replace the fresh 
vegetables. Maillart (Corres.-Blatt f. 
Schweizer Aerzte, June 3, 1916), 

In a comprehensive study of the 
blood regeneration following simple 
anemia in the dog, the writers found 
that Blaud’s pills are inert when added 
to various diets which do not favor 
rapid blood regeneration. In an ani¬ 
mal bled till the pigment was re¬ 
duced to a level of 40 per cent, below 
normal, followed by the institution 
of a meat diet, the pigment level nor¬ 
malized within 4 weeks. With milk 
diet the 40 per cent, level persisted. 
A fasting animal with access to water 
could reproduce the hemoglobin, 
showing that the body could reorgan¬ 
ize its elements into hemoglobin. 
Spinach was found to return the level 
of hemoglobin to normal and keep 
it there. Milk gave the minimum re¬ 
generation, Cooked liver and cooked 
beef heart produced the best regener¬ 
ation. Hooper, Robscheit and Whip¬ 
ple (Amer. Jour. Physiol., Sept. 
1920). 

[It should be borne in mind that ex¬ 
periments in animals, particularly where 
the morbid process is produced artificially, 
do not always portray faithfully a blood 
disorder in man,—E d.] 

In the management of acute ane¬ 
mias of grave character (i.e., post¬ 
hemorrhagic variety) the direct trans¬ 
fusion of an homologous blood, may 
prove to be a life-saving expedient. 
The technique and other details of 


this operation are discussed else¬ 
where in this work. (See Venesec¬ 
tion AND Transfusion.) 

In 8 instances of blood transfusion 
because of simple secondary anemia 
or because of anemia and malnutri¬ 
tion, the blood was usually obtained 
from the father or mother after phys¬ 
ical fitness was demonstrated by the 
absence of agglutination and hemo¬ 
lysis. The blood was withdrawn 
from a vein of the donor into a syr¬ 
inge and injected directly into the 
vein of the infant. The syringe was 
washed out with sterile salt solution 
before being refilled with blood. 
Satisfactory results were obtained in 
all but 1 case, although the children 
were all under two years of age, both 
in the digestive capacity and general 
health, C. G. Kerley (Amer. Jour, 
of Obstet., Ixxvi, 713, 1917). 

The writer advocates transfusion 
before operation in severe secondary 
anemias, on the basis of a case of 
uterine fibromyomata complicated by 
severe uterine hemorrhage of 6 weeks’ 
duration. For 6 days following the 
patient’s admission her general con¬ 
dition became much worse, the red 
blood count falling to 845,000 per 
cubic millimeter, when 600 c.c. of 
citrated blood were transfused into 
the median basilic vein. The effect 
was most decided. Three days later 
the temperature was normal, the 
vomiting had ceased, and control 
over the bladder and rectum had re¬ 
turned. The red cells had risen to 
3,485,000, and the white cells had fal¬ 
len to 29,000 per cubic millimeter. 
Fifteen days later a subtotal hyster¬ 
ectomy was performed. This was 
followed by uninterrupted recovery, 
H. Williamson (Proc. Royal Soc. 
Med., London, xiii. Sect. Gynec. and 
Obstet., 149, 1920). 

Hydrotherapy and general mas¬ 
sage must be regarded as most useful 
aids to the drug treatment of anemia, 
and such measures, when sanely car¬ 
ried out, will do much to promote 
adequate excretion and secretion, to 


ANENCEPHALY. 


641 


maintain a healthy balance of the 
blood and lymph streams, and to 
stimulate oxyg-en and carbon dioxide 
interchange. A regimen of fresh 
air, sunshine, and gentle exercise 
is of great value, added to the fore¬ 
going hygienic measures, and in this 
connection it is interesting to recall 
Gardinhhi’s statement, Recently voiced 
by P^ope, that the presence of sunlight 
promotes the absorption of iron from 
the liver, where this metal, after inges¬ 
tion, is presumably stored in no in¬ 
considerable quantity. 

Very small doses of salvarsan— 
0.05 or 0.075 Gm. to 1% grain)— 
is a simple and harmless method of 
giving arsenic. It was extremely 
effectual in 50 cases, increasing the 
weight, improving the blood-picture 
and subjective symptoms in all forms 
of secondary anemia and mild tuber¬ 
culosis. From 10 to 15 injections 
were given, the course being repeated 
after an interval of a few weeks. 
Kail (Munch, med. Woch., July 7, 
1914). 

The X-'rays in large doses destroy 
the bone marrow, but in small doses 
enhance its activity. This explains 
their beneficial effects in severe ane¬ 
mia observed by the writers with 
very mild exposures, the rays beihg 
filtered through 2 or 4 mm. of alumi¬ 
num. Vaquez and Aubertin (Arch, 
des mal. du Coeur, Sept., 1915). 

Case of von JakscWs anemia in a 
child of 18 months on whom the 
writer performed a splenectomy, with 
good results. Red count, 2,700,000; 
hemoglobin, 45 per cent.; white cells, 
12,000; polynuclears, 47 per cent.; 
normoblasts and megaloblasts were 
present. A spleen weighing 230 
grams, showing a high grade meloid- 
ization, was removed May 11, 1915. 
Three weeks after the operation the 
red blood count had risen to 4,500,- 
000, and the hemoglobin to 60. Pool 
(Annals of Surg., Ixiii, 122, 1916). 

In von Jaksch's anemia the most 
prominent feature of the symptom- 


complex is an enlarged spleen, but 
the other hematopoietic organs must 
be involved more or less extensively. 
The treatment has been unsatisfac¬ 
tory in the majority of cases; in 6 
cases, however, treated by splenec¬ 
tomy the operation was followed 
by immediate clinical irnprovement. 
Frequently^ they tend to recover, 
when almost any treatment may be 
followed by improvement, while 
others progress to a fatal issue in 
spite of any treatment. R. G. Still¬ 
man (Amer. Jour. • Med. Sci., Feb., 
1917). 

J. C. Da Costa, Jr. 

AND 

Henry D. Jump, 

Philadelphia. 

ANENCEPHALY. —This mon¬ 
strosity is characterized by the absence 
in part or in tolo of the brain and spinal 
cord. In most instances, however, the 
central nervous- system is poorly de¬ 
veloped, and the child if borne alive is 
idiotic in proportion as the brain is de¬ 
ficiently developed. A curious and sug¬ 
gestive feature of this condition is that 
’ the adrenal cortex is poorly, if at all, de¬ 
veloped. Thus, Apert (La Presse Med., 
Oct. 28, 1911) states that this fact was 
first observed by Morgagni. It has been 
verified in hundreds of cases of anen- 
cephaly, pseudoencephaly, cyclopia and in 
a limited number of cases of hydrocephaly 
and microcephaly. 

In a case reported by F. B. Talbot 
(Med. Rec., Sept. 11, 1915) the child was 
blind, deaf, and apparently idiotic, and its 
metabolism was extremely low. An oper¬ 
ation for the possible relief of the blind¬ 
ness showed that the hemispheres were 
absent and replaced by cerebrospinal fluid. 
When the spinal cord is alone developed 
more or less, the movements are mainly 
reflex, as stated by Bronwer (Nederl. 
Tijdsch. voor Gyn., Aug. 16, 1913). He 
enumerates among the features to be as¬ 
certained the existence of syphilis, through 
the Wassermann test. Alfred Gordon 
(Med. Rec., Jan. 31, 1914) failed to obtain 
a positive reaction in the father of a case 
observed by him, but a history of alco- 


642 


ANESTHESIA. 


holism and of conception during a period¬ 
ical spree. 

The writer was able to diagnos¬ 
ticate a case of anencephaly before 
birth by means of X-ray. This in¬ 
dicates the value of radiography 
where Cesarean section is to be per¬ 
formed, this operation being rendered 
unnecessary where the presence of a 
monster is ascertained, J. T. Case 
(Surg., Gynec. and Obstet, Mar., 
1917). S. 

ANESIN. See Chloretone. 
ANESTHESIA. —While the various 

anesthetics: Ether, chloroform, etc., are 
considered under their respective head¬ 
ings, many features of special interest can 
only be brought out by considering these 
agents collectively. Hence the present 
section. 

CHOICE OF ANESTHETICS.—A. S. 

McCormick (Summit Co. Med. Soc., Ak¬ 
ron, Ohio, Feb. 1, 1916) states that while 
the anesthetics most generally used are 
ether, nitrous oxide, chloroform, ethyl 
chloride, their relative merits are as 
follows: 

Ethyl Chloride: The anesthetic and 
toxic stages are so close that it is too 
dangerous. Death rate, 1-2550 (1905-11). 
Its chief use is to begin anesthesia, for 
which it is quick and efficacious, but even 
then it is too dangerous. 

Chloroform: Its many good points are 
outweighed by its one bad—that of being 
a dangerous heart depressant. Death rate, 
1-2000. In warm climates it is safer, the 
rate being 1-8000. 

Nitrous Oxide: Alone it is a dangerous 
anesthetic. It has recently been exten¬ 
sively used, combined with oxygen. While 
safer than the original method, it is losing 
ground as too dangerous. The death rate, 
1905-11, was 1-657. Crile states that in 
unskilled hands it is the most dangerous 
of all anesthetics. 

Ether: Admitted by all as safe, it is, 
beyond question, the safest and best of all 
anesthetics. Figures vary as to death, 
those of Wharton being 1-16,000 cases; 
Baldwin, 1-50,000; Rovsing (Denmark), 
1-56,000; that is, death really caused by 
ether. At the Mayo Hospital ether was 


given 49,037 times in 13 years (1900-12) 
without causing death. 

Ether-oxygen is still safer and better. 
Less ether is required; the anesthesia is 
quiet and just deep enough; the oxygen 
counteracts the otherwise ether irritation; 
the patient’s color is better than under any 
other anesthetic. 

Referring to experience in the late 
war, the writer notes that ether was 
used most extensively on account of 
its convenience and comparative 
safety. Scotch surgeons in the Brit¬ 
ish service clung to chloroform, how¬ 
ever, and their results were excellent. 
Ether-oxygen was a favorite method 
in serious cases, the oxygen from a 
low pressure tank being sent through 
a Shipway apparatus to provide a 
warmed ether vapor. When compact, 
portable American gas-oxygen de¬ 
vices became available, the nitrous 
oxide-oxygen technique won the favor 
of surgeons of all the allied armies. 
It gave promise of obviating to a 
great extent postoperative pneumonia. 
Warmed ether vapor was found quite 
superior to the drop method in every 
respect. Morphine was withheld from 
those in severe shock, as it lowered 
resistance in a marked degree; even 
^ grain (0.016 Gm.) of morphine 
may invite disaster in the presence of 
shock or hemorrhage. Nitrous oxide- 
oxygen proved the anesthetic of 
choice in this condition. It was found 
very dangerous to alter the position 
of patients on the table after anes¬ 
thesia had continued for more than 14 
hour. Five c.c. (D4 drams) of chlo¬ 
roform as a single dose proved to be 
an invaluable method for transient 
anesthesia or analgesia for minor 
procedures. Spinal anesthesia, used 
to some extent in base hospitals, was 
found to be especially dangerous in 
all patients showing a low hemoglobin 
index. W. S. Sykes (Trans. Amer. 
Assoc, of Anesthet.; Jour. Amer. 
Med. Assoc., Aug. 9, 1919). 

Chloroform given by the closed method 
with rebreathing is, according to Gwath- 
mey, one of the safest of all anesthetics. 
It is agreeable, efficient, and easily stopped 
upon the appearance of danger signals. 


ANESTHESIA. 


643 


Late chloroform poisoning does not occur 
and complications are rare. 

Ether given by the vapor method is 
much safer, more agreeable, more effi¬ 
cient, is easily controllable, simpler to ad¬ 
minister, is not accompanied by loss of 
resistance against pus organisms, and not 
so frequently followed by complications 
as ether administered by the open drop 
method; the latter is unscientific. It has 
won unmerited favor within the past few 
years because of its apparent simplicity of 
administration and its supposed safety. It 
should be replaced by the simpler and 
safer vapor method. 

As a simple substitute for intratra¬ 
cheal anesthesia and the complicated 
apparatus required for it, the writer 
recommends vapor anesthesia with 
the Hitz bottle and foot-bellows, the 
latter being cheaper, more portable, 
and as efficient as an electric motor 
blower. The anesthetist soon learns 
to control the volume of air with the 
bellows, and the Hitz bottle is so 
made that any portion of the pumped 
air may be forced through the anes¬ 
thetic agent. A cylinder of oxygen 
is attached for emergency use or to 
augment the atmospheric air current 
from time to time if cyanosis is ob¬ 
served. Use of a chloroform-ether 
mixture is advocated. For induction 
the nitrous oxide-oxygen-ether se¬ 
quence is preferred. For young chil¬ 
dren, the essence of orange-ether se¬ 
quence is best, but for maintenance a 
mixture of chloroform and ether is 
advised. The proportion in most 
cases is, roughly, chloroform 1 part 
and ether 2 parts, but this is varied 
according to the type of patient, and 
the chloroform is increased in the 
mixture when difficulty in mainte¬ 
nance is anticipated. W. H. Long 
(Amer. Jour. Surg., xxxiii, Anes. 
Supp., 77, 1919). 

Oil-ether colonic anesthesia should be 
used whenever the anesthetist is in the 
way, or whenever the element of fear 
dominates the patient. The obese alco¬ 
holic is the best subject for this special 
agent. 

Nitrous oxide gas should never be used 
alone, but always with oxygen. Prelimi¬ 


nary medication of some kind should be 
used in all surgical cases unless contra¬ 
indicated (Gwathmey). 

Minor surgical operations or those 
on the extremities are best done un¬ 
der nitrous oxide oxygen. For all 
operations requiring complete mus¬ 
cular relaxation, especially in abdom¬ 
inal surgery, the nitrous oxide ether 
sequence is the method of choice. 
Chloroform is too dangerous for 
general use, but it may more safely 
be used in combination with ether. 
Intratracheal insufflation is of value 
for thoracic operations. Rectal anes¬ 
thesia with ether in 5 per cent, oily 
solution is suited to operations on 
the head and neck combined with 
local anesthesia. Morphine and atro¬ 
pine injections are to be used sys¬ 
tematically. A. R. Egana (Semana 
Med., Apr. 29, 1920). 

Addition of a small amount of 
magnesium sulphate to the usual 
hypodermic of morphine greatly in¬ 
creases the value of the hypodermic. 
The author thus converts colonic an¬ 
esthesia into synergistic colonic anal¬ 
gesia, i.c., he obtains complete brain 
block by using much smaller amounts 
of ether than heretofore and adding 
to it the effects of the combined 
morphine and magnesium sulphate. 
Furthermore, with 3 hypodermic in¬ 
jections, each of Vh grain (0.008 Gm.) 
of morphine and 2 c.c. (lii dram) of 
magnesium sulphate, supplemented by 
nitrous oxide and oxygen (the latter 
in high percentage) an analgesic state 
with unconsciousness and complete 
relaxation is secured which entirely 
eliminates the necessity for ether. 

Morphine, whenever indicated, may 
be given in a 25 per cent, sterilized 
solution of chemically pure mag¬ 
nesium sulphate. This increases the 
value of the morphine from 50 to 100 
per cent. J. T. Gwathmey (Jour. 
Amer. Med. Assoc., Ixxvi, 222, 1921). 
PRELIMINARY NARCOTICS.— 
Blumfeld (Proc. Roy. Soc. Med., viii. Sect. 
Anes., 15, 1915) held that the giving of 
narcotics preliminary to the anesthetic 
has great value in some cases, while in 
others it should not be used. As a routine 


644 


ANESTHESIA. 


measure these drugs should not be em¬ 
ployed with the single exception of atro¬ 
pine. He had never seen or heard of any 
ill-effects from it so used. Scopolamine 
and morphine seem risky drugs to pre¬ 
scribe indiscriminately. After the hypo¬ 
dermic the patient should be undisturbed 
and should not walk to the operating 
room. The main advantages of prelim¬ 
inary narcotics are: (1) a quiet induction; 
(2) less anesthetic used; (3) diminished 
after-effects. Atropine contributes to the 
first and second. 

Hewitt (Proc. Roy. Soc. Med., viii, Sect. 
Anes., 15, 1915) had found preliminary 
narcotics valuable when used with dis¬ 
criminating care. The anesthetist should 
be familiar with his patient’s condition, 
^areful notes of 266 cases in which he had 
used morphine, atropine, and scopola¬ 
mine in different combinations show that 
atropine is a very valuable anesthetic, pre¬ 
venting undue secretion and causing little 
after-vomiting. It has no contraindications. 
Scopolamine is to be feared, 4ioo grain 
(0.00065 Gm.) having caused in an elderly 
man profound narcotization. The injec¬ 
tions were made % hour beforehand. 
Morphine is strongly contraindicated in 
certain cases: nose, throat, and tongue 
operations with hemorrhage in which it is 
highly important that the reflexes should 
return rapidly. 

Boyle (Proc. Roy. Soc. Med., viii. Sect. 
Anes., 15, 1915) urged the advantage of 
the patient’s seeing the anesthetist a day 
or 2 before operation, so that he might 
have a better knowledge of the patient’s 
condition. He had witnessed the use of 
morphine, atropine, and scopolamine in a 
war hospital. It added greatly to the 
comfort of both the soldiers and surgeons, 
the only drawback being the extreme 
thirst and dryness of the throat. 

MISCELLANEOUS FACTORS— 
P'right. —Badly frightened patients, accord¬ 
ing to Scholz (Beit. z. klin. Chir., June, 
1914), are inclined to tachycardia, false 
angina pectoris, polyuria, glycosuria, nerv¬ 
ous diarrhea, transient numbness, angio¬ 
neurotic edema, shallow, rapid breathing, 
with occasional deep breaths, tremor, pal¬ 
lor and dryness of the mouth. Carbon 
dioxide seems to be a special product of 
extreme dread. The blood-pressure in 


such patients suffered a constant and regu¬ 
lar decline as the ether or chloroform was 
administered, until consciousness was en¬ 
tirely lost; the patient is exposed to vari¬ 
ous dangerous reflex processes, especially 
to reflex syncope from irritation by the 
anesthetic of the terminals of the trigem¬ 
inus in the nose, the reflex action from 
this involving the vagus terminals in the 
heart and the respiration center in the 
medulla. This can be warded off by cocain¬ 
izing the nose. The fatalities as general 
anesthesia is just commenced are un¬ 
doubtedly due to this dangerous reflex. 
The whole secret is to tranquilize the 
patient, avoid anything suggesting force, 
and refrain from beginning to operate too 
early. Persons with marked dread of the 
operation are exposed to peculiar dangers 
at the first whiffs of the anesthetic.. 

Breathing Test to Ascertain Condition of 
Heart Muscle. —General anesthesia is par¬ 
ticularly dangerous to persons suffering 
from myocardial changes, a condition 
which does not permit of ready recogni¬ 
tion. W. A. Schtange (Roussky Vratch, 
Jan. 18, 1914) found that while a healthy 
person can suspend breathing from 30 to 
40 seconds, owing to the vigor of the 
heart muscle, in persons with weak hearts 
the time is shortened to 20 or even 10 sec¬ 
onds. The patient, seated in a chair, is 
told to take a moderately deep inspiration, 
and, with the mouth closed, to hold his 
breath as long as he can. The shorter the 
time the patient can suspend breathing, 
the greater the danger of an anesthetic, 
the latter being contraindicated if the time 
is less than 20 seconds. 

Pre-anesthetic Diet. —Opie and Alford 
(Jour. Amer. Med. Assoc., Mar. 21, 1914), 
in a series of experiments upon animals, 
using chloroform as an anesthetic, and 
employing fats and meats as well as car¬ 
bohydrates as foodstuffs, found animals 
which received carbohydrates survived; 
whereas all of those which received meat 
and fat died. The use of fats increased 
the susceptibility of the liver to necrosis 
of chloroform, while a carbohydrate diet 
seemed to protect the liver from this 
disaster. 

Postoperative Analgesia. —Postoperative 
analgesia recommended by B.Van Hoosen 
(Boston Med. and Surg. Jour., clxxx, 556, 


ANESTHESIA. 


645 


1919), to secure painless convalescence for 
surgical patients: Morphine, 1/52 grain 
(0.002 Gm.), and scopolamine, Vl’oo grain 
(0.0003 Gm.), are given every 4 hours by 
hypodermic injection for 24, 36 and, in 
very painful cases, 48 hours after opera¬ 
tion. In 452 cases so treated the effects 
were found to’ be most beneficial to both 
patient and nurses. The method greatly 
decreases complicating stomach symp¬ 
toms, shortens convalescence, prevents 
dread of future operations, and facilitates 
the work of the nurse. For the first 2 
days after operations, the patients had not 
only marked analgesia but also some 
amnesia. 

Trendelenburg Position as Souree of Dan¬ 
ger. —In MacCardie’s opinion (Proceed. 
Roy. Soc. of Med., Sect, of Anes., Apr., 
1914), anesthetics have frequently been 
blamed for complications which are really 
induced by the Trendelenburg posture, es¬ 
pecially when the angle of inclination has 
exceeded 45 degrees. It not only pro¬ 
motes copious venous hemorrhage, and 
embarrasses pulmonary ventilation, but 
also puts an additional strain on the heart. 
Likewise it seems to be an important fac¬ 
tor in the occurrence of post-operative 
pneumonia and bronchitis; and Zweifel 
holds it occasionally responsible for post¬ 
operative intestinal obstruction, surgical 
emphysema, apoplexy and acute dilatation 
of the stomach. 

Shoek During General Anesthesia. —F. C. 
Mann (Trans. Amer. Med. Assoc.; N. Y. 
Med. Jour., June 16, 1917) states that the 
most common of its causes is free hemor¬ 
rhage. All persons do not react similarly 
to loss of blood. Trauma to the viscera 
is a common cause when accompanied by 
loss of circulatory fluid in the traumatized 
areas. Excessive nerve irritation is prob¬ 
ably of rarer occurrence than clinical re¬ 
ports indicate. In cases of fractures and 
trauma to large areas of fat, pulmonary 
fat embolism might act as cause. The 
ductless glands, particularly the adrenals, 
are sometimes factors, possibly as primary 
active agents or owing to the low blood- 
pressure and the changes incident to the 
condition itself. Deep etherization may 
produce most of the symptoms of shock. 

A. Bowlby (Lancet, Jan. 17, 1920) notes 
that where anesthesia must be used shortly 


after recovery from the more urgent 
symptoms of shock, ether, though un¬ 
likely to cause pulmonary conditions or 
vomiting when warmed, produces a dan¬ 
gerous and prolonged lowering of blood- 
pressure. The most satisfactory results 
are obtained with nitrous oxide and oxy¬ 
gen combined with local infiltration of the 
region of the incision, particularly in 
abdominal operations. 

Post-anesthetie Intoxieation. —During an¬ 
esthesia the reserve of glycogen in the 
system is rapidly consumed, and if this 
supply were replenished by the adminis¬ 
tration of glucose to the patient, the pos¬ 
sible harmful consequences of anesthesia 
could be in a large measure avoided. 
Chauvin and Oeconomos (Presse med., 
Dec. 18, 1912) administer it as prophylactic 
in the following form: 

IJ Glucose . 5v (150 Gm.). 

Tincture of mix 

vomica . Rvlij (0.5 c.c.). 

Tincture of cinna¬ 
mon . iTLxlv (3 Gm.). 

IVater, enough to 

make . 5^ (*500 c.c.). 

M. 

Where post-anesthetic intoxication is al¬ 
ready established, glucose should be freely 
administered by mouth, rectum, and even 
intravenous injection. As in diabetic coma, 
alkalies should also be given. 

Post-anesthetic Vomiting. —Renton (Brit. 
Med. Jour,. Dec. 6, 1913) advises to raise 
the head of the patient’s bed 12 inches, 
on blocks, leaving it in this position 
(Fowler’s) 24 to 36 hours. 

E. M. Barker (Brit. Med. Jour., Jan, 10, 
1914) recommends the application after 
anesthesia, of eau de Cologne on a mask 
immediately, and allow patient to inhale 
this for half an hour after being placed in 
bed, the Cologne-water being renewed as 
required. 

Vomiting. —D’Arcy Power (Pract., July, 
1920) states that when vomiting is not 
very severe, sips of hot water may be 
given. In more persistent cases 15 grains 
(1 Gm.) of sodium bicarbonate may be 
dissolved in a tumblerful of hot water; the 
patient vomits it directly, but the sickness 
afterwards subsides. In very severe cases 
give nothing by mouth, but administer a 






646 


ANESTHESIA. 


sedative enema, consisting of potassium 
bromide and chloral hydrate, of each 20 
grains (1.3 Gm.), and mucilage of starch, 
2 ounces (60 c.c.). When vomiting has 
been unduly prolonged it is sometimes a 
good plan to feed the patient solid food 
rather than to restrict him to “slops.” 

C. J. Larkey (Jqur. Med. Soc. of N. J., 
xiv, 8, 1916) attributes post-anesthetic 

vomiting to the acidosis (q. v. this volume) 
which follows the physicochemical com¬ 
bination of the anesthetic with the lipoids, 
a process followed in hernia by increased 
acidity of the cell content and increased 
capacity for water. To prevent acidosis 
the preoperative preparation should in¬ 
clude a regular diet with plenty of starchy 
foods up till noon of the day before oper¬ 
ation, then a supper of cereals, milk with 
albumin, water, and sugar. If acetone is 
present in the urine the proteids should 
be cut down and the carbohydrates in¬ 
creased. Water containing calcium is use¬ 
ful, while the administration of sodium bi¬ 
carbonate and lactose, 1 dram (4 Gm.) of 
each every 4 hours for 48 hours before 
operation is advisable. Following opera¬ 
tion the patient is given a 5 per cent, solu¬ 
tion of anhydrous dextrose by the drip 
method per rectum, using 250 c.c. (8 
ounces). 

Untoward Effects of Adrenalin.—Lewy 
(Brit. Med. Jour., Sept. 14, 1912) found 
that adrenalin exerted a very pronounced 
cardiac effect in chloroformed subjects. 
Within a few seconds, injection of 5 
minims (0.3 c.c.) of the 1:1000 solution 
caused pulse acceleration and a raised ten¬ 
sion; it became more rapid and was less 
readily felt owing to diminished excursion. 
It may, or may not, be perceptibly irregu¬ 
lar at the wrist; a few temporary pauses 
were noted, and then the heart suddenly 
ceased beating; the pupils dilated widely, 
and intense pallor supervened. Respira¬ 
tory phenomena followed; a few deep 
breaths were taken, and the respirations 
ceased also. The writer concludes that it 
is unsafe to inject adrenalin into the veins or 
vascular tissues of a patient lightly un¬ 
der the influence of chloroform. It may 
be safely injected just previous to the in¬ 
duction, however, or into a patient fully 
under chloroform, or into a patient anes¬ 
thetized to any degree with ether. In the 


case of light chloroform anesthesia ^the 
risk taken is unjustifiable. 

[The injection of adrenalin into the 
veins is dangerous under any circum¬ 
stance. S.] 

Depree (Brit. Med. Jour., Apr. 26, 1913) 
observed sudden death from cardiac ar¬ 
rest after the injection of 5 minims (0.3 
c.c.) of a 1:1000 solution of adrenalin in 
the nose of a patient who had been anes¬ 
thetized with chloroform. At the time of 
the injection anesthesia was light, the cor¬ 
neal reflex being brisk, and no more chlo¬ 
roform was given. All attempts to resus¬ 
citate the heart failed. 

NARCOANESTHESIA.—This term is 
used by Henry Beates (N. Y. Med. Jour., 
Jan. 13, 1917) to identify a method which 
is asserted to have secured unconscious¬ 
ness and perfect freedom from pain and 
exert a minimum of injurious effects. 
About 2 V 2 or 3 hours before the opera¬ 
tion, the patient receives a hypodermic in¬ 
jection of grain (0.0013 Gm.) of scopo¬ 
lamine hydrobromide and % grain (0.01 
Gm.) of morphine. One-half hour later, a 
second injection is administered and an 
hour later a third, which may or may not 
contain morphine, as the susceptibility of 
the patient is more or less apparent. At 
the time of the third injection an enema 
of 2 fluidounces (60 c.c) each of whisky 
and spiritus aetheris compositus is given. 
By the time the hour for the operation has 
arrived, the patient is, as a rule, in a con¬ 
dition of complete narcoanesthesia. The 
face is more or less flushed. Occasionally 
there is moderate pallor. The respirations 
resemble those of profound sleep and, be¬ 
cause of the morphine and the suscepti¬ 
bility of the patient to its action, there 
may be a retardation of the respiratory 
rate to as low as 10 or 8 to the minute. 
There has been no material disturbance ot 
the renal functions observed in any case; 
this suggests that even with the coexist¬ 
ence of renal degenerative lesions narco¬ 
anesthesia is safe. Operations upon the 
biliary tract, herniae, appendicectomies, 
pelvic operations of major type, such as 
hysterectomy, plastic work in the pelvic 
canal, operations upon the kidneys and 
rectum, constitute a group that may be 
most admirably subjected to narcoanes¬ 
thesia and performed with the leisure 


ANESTHESIA. 


647 


necessary for thorough surgery. One im¬ 
portant precaution is the patient must 
never be left alone, or without an intelli¬ 
gent attendant, as there is danger of 
strangulation. Dr. Wayne Babcock sug¬ 
gests the placing of a wisp of cotton to 
the nostril, which serves as an indicator 
of the ingress and egress of breath, thus 
preventing a mistake in considering the 
convulsive movements of strangulation for 
those of respiration. The patient sleeps 
from 3 to 7 hours after the operation and 
awakes often without any discomfort ex¬ 
cept slight dryness of the nose and throat. 

LOCAL ANESTHESIA.—According 
to R. E. Farr (Amer. Jour. Obstet., Ixxx, 
653, 1919), the method of choice in local 
anesthesia is infiltration when it does not 
interfere with the anatomical relation of 
the tissues, but in some cases, hernia for 
example, nerve blocking is recommended. 
Abolition of the reflexes of the abdominal 
wall is the ideal in abdominal operations 
under local anesthesia. Vertical retraction 
and great care in the handling of the tis¬ 
sues are important points. 

Eggleston and Hatcher (Jour. Am. Med. 
Assoc., Oct. 25, 1919) assert that acute 
intoxication in man from local anesthetics 
is far more common than is indicated by 
the number of recorded cases. In over 
300 experiments in cats it was found that 
when large fractions of the minimal fatal 
doses are injected intravenously at inter¬ 
vals of from 15 to 20 minutes, or when 
relatively dilute solutions of the drugs are 
injected slowly and nearly continuously, 
the several drugs can be divided into 2 
groups as regards rate of elimination. 
Group 1 includes alypin, apothesin, beta- 
eucaine, nirvanin, procaine (novocaine), 
stovaine, and tropacocaine, all of which are 
rapidly eliminated, so that several times 
the minimal fatal dose can be injected in 
the ways just mentioned in periods of 1 
or 2 hours without causing death. Group 
2 includes cocaine and holocaine, which 
are much less rapidly eliminated and there¬ 
fore cause death in much smaller total 
doses when given as described. The elim¬ 
ination of all the local anesthetics is ac¬ 
complished almost entirely by their de¬ 
struction in the liver. 

Epinephrin and artificial respiration 
should prove effective as a resuscitative 


measure in many cases of acute poisoning 
in man. To diminish the likelihood of in¬ 
toxication from the subcutaneous injection 
of local anesthetics in man, epinephrin 
should always be added to their solution. 

Novocaine (procaine) being the safest 
anesthetic known, a more dangerous drug 
should not be used, according to Farr 
(Trans. Amer. Med. Assoc.; Med. Rec., 
May 15, 1920). Many children are in a 
bad condition following the use of a gen¬ 
eral anesthetic, and the nature of the an¬ 
esthetic often decides the issue. A child 
can be restrained on an arm table set at 
right angles to the operating table. The 
feet are attached by bandages to the oper¬ 
ating table, and the nurse holds the arms 
above the elbow. As a rule the child needs 
restraint only while the anesthetic is being 
given. One should always be prepared to 
reinforce the local anesthesia with general 
anesthesia; but it is rarely necessary. 
Farr refers to a series of 129 cases of chil¬ 
dren operated under local anesthesia and 
in only 9 of whom there was any pain; 
when this occurs it is due to an error in 
technique. 

COMPARATIVE MERITS OF VA¬ 
RIOUS LOCAL ANESTHETICS.—G. 

MacGowan (Calif. State Jour, of Med., 
Jan., 1916) holds that a local anesthetic to 
be valuable must not of itself be a cause 
of pain, either before its action is estab¬ 
lished or after it has ceased. None of the 
drugs are used pure, but all need to be 
dissolved in fluids isotonic with the juices 
that bathe the body cells, such as a 0.9 per 
cent, solution of common salt. Cocaine, 
the first local anesthetic to be discovered, 
has been abandoned because of its dis¬ 
advantages except in eye and nasal sur¬ 
gery, and sometimes in urethral opera¬ 
tions where the newer and safer anes¬ 
thetics are inactive. Tropacocaine is the 
ideal agent for spinal anesthesia. Beta- 
eucaine does not differ widely from co¬ 
caine; as a protoplasmic poison, it pro¬ 
duces the same symptoms, but the dose 
required is greater. It is slightly less 
powerful as a local anesthetic, does not 
diffuse so well, and is more irritating. Its 
solutions are stable and can be sterilized 
by boiling. Acoin is a dangerous poison, 
and is decomposed readily by alkalies. 
Holocaine anesthetizes the eye without 


648 


ANESTHESIA. 


dilating the pupil, producing dryness of 
the cornea, or preventing bleeding. Chlo- 
retone or anesol is very irritating. Ortho¬ 
form, anesthesin, subcutin, propesin, and 
zykloform are all slightly soluble powders 
with anesthetic properties when brought 
in contact with exposed nerve filaments or 
endings. They are used upon the skin in 
dusting powders or salves, in the rectum 
or vagina as suppositories or salves, and 
are also useful in the nose, throat, and in¬ 
testinal tract, especially the stomach. The 
most efficient of the group is anesthesin, 
over which the others possess no advan¬ 
tages. Stovaine has been recommended 
for spinal anesthesia, but is irritating and 
painful for infiltration anesthesia. In a 1 
per cent, solution it is useful as a local 
anesthetic when used by instillation for an 
instrumental examination of the urethra 
and bladder. Alypin is a close relative of 
stovaine, is readily soluble in watery solu¬ 
tions, is less active and more irritating 
than cocaine when used hypodermically, 
and its toxic symptoms are similar to 
those of the latter. Novocaine is but 
feebly poisonous, its watery solutions up 
to 10 per cent, are not irritating; it may 
.be sterilized and resterilized without 
^marked effect upon its anesthetic proper¬ 
ties, which are greater than those of any 
other drug used for local anesthesia, when 
combined with suprarenine, with the ex¬ 
ception of cocaine. It can be applied pure 
.to the cornea and to freshly denuded sur¬ 
faces without causing pain or subsequent 
edema. For infiltration anesthesia isotonic 
^solutions of %, 1, 2, and 4 per cent, are 
^the most useful; greater concentrations 
are not necessary and should not be used, 
even though it is only feebly toxic. Hydro¬ 
chloride of quinine and urea in watery 
solutions of from 0.25 to 1 per cent, causes 
the formation of a fibrinous exudate in 
tissues infiltrated with it, which delays the 
healing of wounds. Tetanus has been ob¬ 
served after this salt has been used. Its 
one valuable quality is the length of time 
its anesthetic effects last, sometimes for 
many days, on account of which it may be 
used to inhibit pain in intense and per¬ 
sistently localized neuritis, and in blocking 
the sensation of itching in circumscribed 
and chronically thickened patches of 
eczema. 


Benzyl alcohol was found by. the 
writer to be a fairly efficient anes¬ 
thetic for intact mucous membranes, 
greatly surpassing procaine, ranking 
about with alypin and betaeucaine, 
and somewhat weaker than holocaine 
or cocaine. Its action is not as last¬ 
ing as that of cocaine, and even 1 
per cent, solutions produce much 
smarting. Sollmann (Jour. Pharm. 
and Exper. Therap., July, 1919). 

ANESTHESIA ACIDOSIS.—In gath¬ 
ering data to indicate the character of the 
operative risk, it has been customary for a 
long time, as stated by H. Morriss (Jour. 
Amer. Med. Assoc., May 12, 1917), to em¬ 
ploy uranalysis, blood counts, hemoglobin 
determinations and estimations of the ar¬ 
terial tension. It seems advisable often • 
to add to these the determination of 
what has been called the “alkali reserve”; 
for postoperative nausea and vomiting, 
menacing convalescence, may depend on 
an acidosis for which the anesthetic is 
responsible. Under normal circumstances 
the acid-base equilibrium is remarkably 
stable. The mechanism involved in the 
maintenance of the equilibrium comprises: 
(1) the elimination of carbon dioxide by 
the lungs; (2) the excretion of acid salts 
by the kidneys and sweat glands; (3) the 
presence of “buffer” substances in the 
blood which include the bicarbonates, 
phosphates, and probably proteins; (4) the 
production of ammonia at the expense of 
urea, and (5) the influence of the baro¬ 
metric pressure (oxygen tension) to which 
the individual is accustomed, a factor as 
yet imperfectly understood. It has been 
demonstrated that the lungs take a leading 
part in the regulation of the acidbase equi¬ 
librium of our bodies. The carbon dioxide 
which the lungs excrete has acid proper¬ 
ties; when in the blood it is neutralized 
through combination with alkali. The 
excess of available alkali is termed the 
alkali reserve. This may be estimated in¬ 
directly by the determination of the car¬ 
bon dioxide in the alveolar air, or of the 
capacity of the blood plasma to combine 
with carbon dioxide. 

In anesthesia there results a com¬ 
pensated acidosis in from 30 to 85 per 
cent, and an uncompensated acidosis 
in from 15 to 20 per cent, of cases. 


ANESTHESIN. 


649 


The protection of the patient from 
acidosis rests in limiting suboxida¬ 
tion and in supplying the body with 
alkali. The acids are usually neutral¬ 
ized as they are formed by sodium 
bicarbonate, ammonia, and less easily 
mobilized bases, such as calcium and 
magnesium. The symptoms vary 
from headache, nausea and vomiting, 
gas pains and mental dullness, to 
coma and death. The following factors 
influence uncompensated acidosis: ex¬ 
treme age, impaired kidney function, 
exhausting diseases, prolonged sepsis, 
duration and depth of anesthesia, 
hemorrhage, and preoperative fasting. 
Shock is always associated with un¬ 
compensated acidosis. A patient 
showing before operation a low bi¬ 
carbonate content should be given 
the benefit of alkalinization with 
sodium bicarbonate, though further 
studies may show the use of mag¬ 
nesium and calcium to be equally im¬ 
portant. Too much alkali may do 
harm; therefore, a second analysis 2 
hours after alkalinization should be 
made, to ascertain whether the de¬ 
sired result has been attained. S. P. 
Reimann (Trans. Amer. Assoc, of 
Anesthet.; Jour. Amer. Med. Assoc., 
Aug. 2, 1919). 

ANESTHESIN. — Anesthesin is, 

chemically, ethyl para-aminobenzoate [Co- 
H 4 .NIl 2 .COOC 2 TIr)]. It occurs as a white, 
odorless, and tasteless powder, almost in¬ 
soluble in cold water, with difficulty solu¬ 
ble in hot water, sparingly soluble in fatty 
oils (2 to 3 per cent.) and in dilute glyc¬ 
erin, easily soluble in alcohol, ether, chlo¬ 
roform, benzene, and acetone. It melts 
at 90° to 91° C. Though decomposed by 
prolonged boiling, it can be rendered 
sterile without deterioration when dis¬ 
solved in oils. Alkalies and alkaline car¬ 
bonates are incompatible with it, remov¬ 
ing the ethyl group to form alcohol and 
setting free para-aminobenzoic acid. 

PHYSIOLOGICAL ACTION.—The 
most conspicuous feature of anesthesin is 
its local anesthetic property. The drug 
differs radically from cocaine in that it is 
but very feebly toxic and is insoluble in 
water. The low toxic power was shown 


in the experiments of I^inz, who adminis¬ 
tered 0.6 Gm. (10 grains) of the drug in 
20 c.c. of oil by stomach tube; on the next 
day the animal was in good health, with 
urine normal. The dose required to kill 
was found to be 1.15 Gm. (18 grains) per 
kilo of animal, the symptoms produced 
being paralysis, gradual loss of sensibility 
in the hind limbs, and dyspnea terminat¬ 
ing in asphyxia. The drug was also ad¬ 
ministered intravenously in dogs and in- 
traperitoneally in guinea-pigs, with simi¬ 
lar results indicative of a low degree of 
toxicity. 

The intoxication produced by anesthesin 
is in some ways comparable to that of 
acetphenetidin; massive doses lead to the 
formation of methemoglobin, with conse¬ 
quent methemoglobinuria. 

Anesthesin placed upon the tongue pro¬ 
duces a feeling of numbness in two to 
three minutes. By virtue of the insolu¬ 
bility of this substance, its anesthetic 
action is more strictly localized than that 
of cocaine. It is also feebler, but is more 
enduring. It is said to exert no action on 
the vessels at the site of application, caus¬ 
ing neither vasoconstriction nor vasodila¬ 
tion. Over orthoform it has the advan¬ 
tages of being more stable and practically 
non-irritating. 

THERAPEUTIC USES. — Internally, 
anesthesin, as first demonstrated by von 
Noorden, is useful in conditions of gastric 
hyperesthesia, including nervous dyspep¬ 
sia and gastric ulcer. The dose is 0.2 to 
0.5 Gm. (3 to grains) ten to fifteen 
minutes after the ingestion of food. In 
laryngeal tuberculosis an insufflation of 
anesthesin has been found by Courtade to 
arrest the severe pain and, therefore, the 
dysphagia for nearly forty-eight hours. 
Earp found it very useful in very painful 
bleeding external hemorrhoids. The bow¬ 
els were moved freely by enemas, hot ap¬ 
plications were used freely, and the fol¬ 
lowing ointment was applied twice daily: 


IJ Anesthesin . 15 grs. (1 Gm.). 

Ergoiin . 1 dr. (4 Gm.). 

Ichthyol .30 mins. (2 Gm.). 

Lanolin . 3 drs. (12 Gm.). 

Petroleum ..to make 1 oz. (31 Gm.). 
Earp also found anesthesin useful in 
perineal eczema which had not yielded to 
other measures. S. 






650 


ANEURISM (BABCOCK). 


aneurism! —definition.— 

An abnormal circumscribed blood- 
tumor containing a cavity communi¬ 
cating with an artery. An aneurism 
consists of a sac, neck, and contents. 
The contents include liquid blood, co- 
agula, and laminated fibrin. Aneu¬ 
risms vary in size from that of a millet 
seed to that of a child’s head. In 
order of frequency aneurisms involve 
the thoracic aorta, popliteal artery, fem¬ 
oral artery, abdominal aorta, subclavian 
artery, innominate artery, axillary 
artery, iliac artery, and the cerebral 
and pulmonary arteries. 

VARIETIES.—Congenital. — Con¬ 
genital aneurisms are extremely rare, 
but they have been reported involving 
the abdominal aorta and ductus Botalli. 
A rare congenital deficiency of the 
elastic elements of the walls of the 
arteries may be the cause of multiple 
aneurisms, especially involving the 
smaller arteries of the body. 

Idiopathic. — Idiopathic aneurisms 
are those arising without obvious 
traumatic injury to the vessel wall. 
They are usually dependent upon dis¬ 
ease of the artery, and constitute 
most of the aneurisms involving the 
great vessels of the trunk, and the 
smaller aneurisms of the brain and 
other viscera. 

Traumatic.—Traumatic aneurisms 
are those resulting from mechanical in¬ 
juries sustained by the arterial wall, 
either in the form of a contusion, in¬ 
cision, or laceration. 

Hernial.—Hernial aneurisms are 
usually small traumatic aneurisms pro¬ 
duced by the bulging of the inner tunic 
through the divided outer layers of the 
arterial wall. 

True.—True aneurisms are those 
having walls formed by the normal 
coats of an artery. It is rare, however, 


to find an aneurismal sac in which in- 
tima, media, and adventitia can all be 
demonstrated. 

False.—False aneurisms are those 
in which the sac is formed by tissues 
other than those derived from the 
wall of the artery. They follow arte¬ 
rial incisions or ruptures, but even 
with these .false sacs the endothelium 
proliferates from the intima of the 
artery into the sac and finally tends 
to line it. 

Diffuse.—Diffuse aneurisms are 
false aneurisms resulting from an ex¬ 
tensive extravasation of blood from 
an open artery. As a rule, they are 
due to traumatism, but they also re¬ 
sult from the spontaneous rupture of 
a diseased artery. 

Dissecting. — Dissecting aneurisms 
are those in which the aneurismal sac 
lies between the coats oi the artery. 
As a rule, they have two mouths, the 
blood entering through one opening, 
separating the layers of the arterial 
walls, and then, at some distance, re- 
communicating by a second opening 
with the arterial stream. These oc¬ 
cur most frequently in the abdominal 
aorta and may produce a very exten¬ 
sive separation of the arterial coats. 

Embolic.—Embolic aneurisms are 
those resulting from the lodgment of 
emboli. By some they are attributed to 
the laceration of the walls of the small 
vessels by calcareous embolic particles. 
It is evident that they may also result 
from degenerative or inflammlatory 
changes of the arterial wall, secondary 
to the lodgment of the embolus. 

Embolomycotic aneurisms develop 
during the course of endocarditis and 
occasionally during some of the acute 
infectious diseases, which form a dis¬ 
tinct group by themselves, differing in 
pathogenesis, clinical course, and prog¬ 
nosis from those developing secondary 


ANEURISM (BABCOCK). 


651 


to chronic arterial changes. They have 
been recognized since 1851. They may 
develop in one of three ways. Most 
commonly they follow an endarteritis 
associated with lodgment of infected 
emboli at the bifurcation of arteries. 
A few cases have been reported which 
developed during the course of infec¬ 
tious diseases unaccompanied by endo¬ 
cardial changes. The possibility of 
traumatic origin is also supported by 
the observation of Ponfick and Thoma 
of calcified emboli in the arterial wall 
and projecting into the aneurism. 
Clinically, embolomycotic aneurisms dif¬ 
fer from those following chronic arte¬ 
rial changes: (1) in developing at an 
earlier age; (2) in frequently being 
multiple, acute and chronic forms often 
occurring in the same individual; (3) 
in the frequent involvement of visceral 
arteries, and (4) in the tendency to 
remain small. A number of cases have 
been reported in which no satisfactory 
explanation is given of the cause. 
About one-fourth of the cases observed 
developed during the third decade of 
life, and about one-fourth during the 
second. 

They are much more frequent in 
males, although the authors have been 
unable to demonstrate the reasons for 
this satisfactorily. They have collected, 
including their own cases, 96 aneurisms 
of this class occurring in 65 patients, 
they frequently being multiple, and re¬ 
port 3 cases observed by themselves. 
The largest proportion of these aneu¬ 
risms occurred in the superior mesen¬ 
teric and cerebral arteries, and in the 
aorta, which is in marked contrast to 
the distribution of the ordinary type 
of chronic aneurisms, which rarely 
occur in the superior mesenteric or 
cerebral arteries. There is nothing 
characteristic in the symptoms, and they 
are not often suspected until fatal ab¬ 
dominal or cerebral hemorrhage occurs. 
Bacteria have been found within the 
wall of the aneurism, showing the 
bacteriological relationship between the 
vegetations on the heart valves and the 
clot in the aneurism. The forms are 
usually the streptococcus and staphy¬ 
lococcus, though other species have been 


reported. In 2 of the author’s cases, 
examinations revealed the pneumococ¬ 
cus. This infection of the aneurisms 
complicates any operation, the patients 
being usually in a critical condition and 
not enduring surgery well. Dean Lewis 
and V. L. Schrager (Jour. Amer. Med. 
Assoc., Nov. 27, 1909). 

Miliary. — Miliary aneurisms are 
very minute aneurisms most fre¬ 
quently observed in the brain or 
lungs. They involve small- or me¬ 
dium- sized arteries and often occur 
in great numbers. 

Fusiform or Ectatic. — In these 
forms the weakened arterial walls 
yield in every direction, forming a 
fusiform, or, rarely, a somewhat cylin¬ 
drical, enlargement. The three coats 
of the artery may be demonstrated in 
the sac; usually there is little clot 
present, and there may be few symp¬ 
toms, unless through weakness of a 
part of the wall a sacculated aneurism 
follows. The walls of the fusiform 
aneurism may be thicker than that of 
the adjacent artery. 

Sacculated.—Sacculated aneurisms 
are due to the bulging of one side of an 
artery. The elastic and muscular layers 
of the artery are not found in the walls 
of the sac. 

ETIOLOGY. — Aneurisms result 
from conditions weakening the ar¬ 
terial wall and increasing the blood- 
pressure. 

Race. — The Anglo-Saxon race is 
most frequently affected; the English 
more than the American, a condition 
attributed to the greater consumption 
of alcohol in England. Aneurism is 
rare in the Asiatic races and in Italy. 
It is three times as prevalent in the 
American negro as in the white race. 

Age .—Aneurism is most frequent be¬ 
tween the ages of 30 and 50, a period 
when degenerative changes in the ar- 


652 


ANEURISM (BABCOCK). 


teries are especially found in those 
engaged in laborious physical work. 

Sex .—Men are affected ten times as 
frequently as women, excepting the 
carotid and dissecting forms of aneu¬ 
rism, which occur more frequently in 
women. The more laborious occupa¬ 
tions of men and their greater tendency 
to dissipation and excess explain the in¬ 
fluence of sex. 

Soldiers, sailors, athletes, cab driv¬ 
ers, furnace men, and others engaged 
in violent, but intermittent exercise are 
especially predisposed to aneurism. It 
is eleven times more frequent in the 
English army than in the civilian, and 
is much more frequent in soldiers than 
in sailors, a condition attributed to the 
pressure and strain from poorly fitting 
clothing and heavy accoutrements. Cab 
drivers, apparently from the pull upon 
the arms, are especially susceptible to 
thoracic aneurism. 

Vessels at the point of flexion and 
extension, such as the popliteal and 
iliacs, or under greater strain, such as 
those of the right arm rather than the 
left, are more frequently involved. Oc¬ 
casionally symmetrical aneurisms, as 
double popliteal aneurisms, occur. 

Those conditions that produce a 
weakening of the arterial wall, espe¬ 
cially all the causes of arteriosclerosis 
and atheroma, are important predis¬ 
posing causes to aneurism. These in¬ 
clude syphilis, alcoholism, rheumatism, 
gout, and the action of mineral poisons 
like lead. 

Arterial disease appears to be rare, 
almost unknown, in animals. Syphilis, 
being probably peculiar to man, is by 
this observation placed more firmly in 
the list of etiological factors. Arterial 
disease in children under 6 years, even 
in those who are victims of congenital 
syphilis, is practically unknown. In 
those from 6 to 15 years it is rare. It 
is found in the initial stage most com¬ 


monly between the ages of 30 and 40 
years. The teratological factor, though 
an undeterminable one, is of great im¬ 
portance. Arterial disease seems to be 
attributable to syphilis in about 32 per 
cent., to tuberculosis in about 16 per 
cent. The facts presented go to show 
that the colored race is affected about 
four times more frequently than the 
white. 

General arteriosclerosis seems to be 
not commonb found with aneurism, and 
its presence may be considered as evi¬ 
dence against the probable development 
of aneurism. 

Staining with selective stains and 
treating with a chemical which digests 
tissue show the elastic tissue to be 
free of histological alterations, sug¬ 
gesting that this tissue undergoes physi¬ 
cal or molecular rather than histological 
change. C. N. B. Camac (Amer. Jour. 
Med. Sci., May, 1905). 

The influence of rheumatism is one 
of great importance, especially in young 
patients. The writer, working with 
Renon, has recently published some im¬ 
portant observations relative to this 
subject. According to the cases col¬ 
lected by this author, the average age 
is from 10 to 16 when the patients have 
usually had several attacks of acute 
rheumatism. Repetition of the disease 
is regarded as an essential factor. The 
appearance of aneurism is preceded for 
some time by the signs of aortic in¬ 
competence and hypertrophy of the 
heart. After a period of considerable 
latency, the symptoms and signs of 
aneurism appear rapidly. They are 
dyspnea, especially marked after effort, 
and characterized by forced inspiration 
without actual oppression. After a 
short time this dyspnea becomes per¬ 
manent, though occasionally varied by 
pseudoasthmatic crises, sometimes at¬ 
tacks of pain resembling angina pec¬ 
toris. The attacks usually appear dur¬ 
ing the first sleep. The patient retires 
to rest in his ordinary condition, but 
suddenly awakes in great agony, com¬ 
plaining of a feeling of constriction in 
front of the chest, air hunger, desire 
to cry out, and violent inspiratory 
efforts are made. The crisis may last 


ANEURISM (BABCOCK). 


653 


from a quarter to one hour, and then 
gradually disappear. Occasionally the 
crises are entirely painful without 
respiratory trouble. Considerable in¬ 
tervals may elapse between them, for 
in one case quoted by the author 
they numbered 2 or 3 during the 
year; in others they are more fre¬ 
quent, occurring once a month, or 
even daily. The diagnosis is con¬ 
firmed by the rapid appearance of 
physical signs. These aneurisms, as 
a rule, affect the upper right costal 
area, and do not differ from those 
usually observed in other cases. 
Aortic aneurism in young rheumatic 
subjects may develop fully in the 
course of a few weeks, sometimes in 
succeeding stages corresponding to 
the rheumatic crisis. After each 
crisis there may be temporary im¬ 
provement, due to retrocession of the 
tumor. This improvement is re¬ 
versed by a fresh crisis of articular 
inflammation. The condition is, there¬ 
fore, progressive, and there is little 
hope of obliteration taking place in 
the sac. Prognosis is usually fatal, 
death often occurring suddenly either 
from hemorrhage or angina pectoris. 
Feytaud (These de Paris, 1906). 

The writer obtained a history of 
syphilis in over 77 per cent, of 34 
cases of aortic aneurism at the Hel¬ 
singfors Hospital since 1900. In the 
10 tested for the Wassermann re¬ 
action, it was positive in 90 per cent. 
The shortest interval since infection 
was 7 years, the longest 35. The 
youngest patient was 30 at the time 
of his death, the oldest 70. In 9 
cases rupture of the aneurism was 
the cause of death, and in 13, inter¬ 
ference with the action of the heart. 
In all but 2 cases the aneurism was 
in the thoracic aorta. Sjoblom (Fin- 
ska Lakare Handl., Iviii, No. 5, 1916). 

Definite evidences of the rather 
commonly syphilitic nature of aneu¬ 
rism detected. The writer found 
spirochacta pallida clustered in foci in 
several cases of aneurism of the 
thoracic or abdominal aorta. Y. 
Manouelian (Bull, de la Soc. Med. 
des Hop., May 28, 1920). 


Only 5 of the author’s 29 patients 
with aortic aneurism had a history 
excluding the possibility of syphilis. 
The outcome was not known in 8 
patients, but 9 were still living after 
intervals of from 16 months to 12 
years. Syphilis plus alcoholism is a 
particularly dangerous combination. 
Martinet (Presse med., Oct. 16, 1920). 

Cardiac hypertrophy, plethora, and 
renal disease are also factors. F'xper- 
inicntally, aneurism may be produced 
by the repeated introduction of adren¬ 
alin into the circulating stream. 

PATHOLOGY.—Idiopathic aneu¬ 
risms develop in an area of atheroma, 
in the situation of an old scar, the point 
of lodgment of an embolus, or other 
weak area in the arterial wall. All 
forms of aneurism are lined by endo¬ 
thelium, excepting the fusiform aneu¬ 
risms ; the media of the artery does 
not constitute a layer of the abnormal 
sac. This means that the normal 
muscular and elastic coats are absent, 
and that the vasa vasorum upon 
which the arterial wall de])ends for 
its nourishment is lacking. The sacs 
of all saccular aneurisms thus tend to 
be weak while blood-pressure causes 
them gradually to distend. 

In the fusiform aneurism all" the 
layers of the arterial walls may remain 
and the wall of the sac may he thicker 
than that of the normal artery, the in- 
tima being thickened by atheroma, the 
adventitia by the deposit of fibrous tis¬ 
sue, while the middle coat is thinned. 
As the inner coats of an artery consti- 
tute not less than three-fourths of 
the thickness- of its wall, containing 
the elastic and muscular layers, and 
also the vasorum supplying the walls 
with nourishment, the thinning, ab¬ 
sence, or damage to these structures 
means a weak and poorly resilient 
wall for the aneurismal sac. 


654 


ANEURISM (BABCOCK). 


In sacculated aneurisms there is 
usually a progressive deposit of layers 
of fibrin against the wall of the sac, 
tending to strengthen the walls and to 
lessen the fluid contents. The lessen¬ 
ing of the fluid contents is important, 
as the pressure on the sac wall varies 
as the square of the diameter of the 
cavity which contains the fluid. 

At times the blood-clot is deposited 
in progressive layers until the entire 
sac is filled, resulting in a spontaneous 
cure. The blood-clot at the periphery 
is white, laminated, and fibrous, al¬ 
though rarely organized into the true 
fibrous tissue, the lack of vasorum pre¬ 
venting vascularization. The aneurism, 
therefore, may consist of a sac or body, 
which in the sacculated form may com¬ 
municate by neck and opening with the 
artery. The sac is strengthened on the 
outer side by the deposit of fibrous tis¬ 
sue, an evidence of the reaction and 
irritation of the tissues against which 
the aneurism presses. 

The sac may contain peripherally 
white, laminated clot; then a layer of 
softer, red blood-clot, and finally fluid 
blood communicating with the blood¬ 
stream. In the cylindrical and fusi¬ 
form aneurisms little or no lining clot 
may be present. 

The size and shape of the sac are 
modified by adjacent pressure. Rota¬ 
tion of the sac may occur so that in a 
fusiform aneurismal sac the orifices of 
the efiferent and afiferent trunks may lie 
at the sides or at the equator of the sac, 
rather than at the poles. 

Matas classifies aneurisms by the 
number of orifices which connect them 
with the parent artery. These orifices 
may only be accurately determined af¬ 
ter the opening of the sac. Fusiform 
aneurisms have two distinct orifices; 
saccular or sacciform aneurisms are 


those which are connected with the 
lumen of the parent vessel by a single 
circular, ovoid, or elongated opening 
through which the blood flows in and 
out the sac. 

The sac of the aneurism may have 
many collateral branches corresponding 
somewhat with the branches normally 
given off by the segment of the arterial 
wall forming the aneurism. These collat¬ 
erals may be functional or impervious 
and containing thrombi. The perianeu- 
rismal circulation may be very impor¬ 
tant in maintaining the collateral circu¬ 
lation after operation upon the sac. An 
aneurism influences the blood-stream, 
absorbing the cardiac wave, so that the 
pulse distal to the sac is delayed and 
weakened. To compensate for this the 
heart may hypertrophy and anastomotic 
channels form. 

The aneurism may so press upon the 
main vessels as to completely inter¬ 
rupt the circulation beyond the sac. 
The adjacent tissues are variously 
afifected. Bone is eroded and pro¬ 
gressively destroyed by the continuous 
pressure, cartilage being much more 
resistant than bone. 

Nerves are stretched, compressed, 
and flattened, at times destroyed, giving 
rise to paresthesia and more rarely 
paralysis. Adjacent veins may be com¬ 
pressed with the production of cyano¬ 
sis and edema, and rarely erosion and 
perforation in the venous channel 
occur. Mucous canals are compressed 
and displaced, while fibrous tissue, ten¬ 
dons, and fascia are flattened, stretched, 
and often incorporated into the sac. 

Thrombi may form in tributary ves¬ 
sels, and emboli may result from the 
dislodgment of clot or fibrin. Cerebral 
complications, such as hemiplegia, in¬ 
farcts in the internal organs, and gan¬ 
grene of the extremities, also occur. 


ANEURISM (BABCOCK). 


655 


SYMPTOMS. —Aneurismal dilata¬ 
tion may occur suddenly from trauma¬ 
tism or a great increase of intravascu¬ 
lar pressure and may be characterized 
by sharp pain and rapid enlargement 
along the course of an artery. The 
sac, however, usually forms slowly and 
at first without pain or any other 
symptom. 

Case of a woman aged 42 years, 
attended by remarkable features. The 
aneurism was eroded and perforated 
the sternum in two places without ever 
causing pain or any other pressure 
symptoms; it presented externally as a 
tumor, and then disappeared under 
treatment by iodide of potassium, the 
skin rupturing without letting out any 
blood. This series of events was re¬ 
peated several times in the course of 
seven years. Death occurred from the 
sudden bursting of the aneurism as the 
patient lifted a pitcher of water. R. C. 
Cabot (Amer. Jour. Med. Sci., April, 
1900). 

The diagnosis of aortic aneurism still 
remains in obscure cases a difficult one, 
and even the X-ray examination maybe 
misleading. Attention called to the 
frequency with which, in aneurism of 
the arch, the left supraclavicular groove 
is obliterated or even bulges, and the 
left external jugular is obviously fuller 
than the right. The anatomical reason 
lies simply in the compression of the 
left innominate vein as a result of the 
dilated arch. A mediastinal tumor may 
have the same effect, but dilatation in 
cases of aortic insufficiency is apparently 
seldom sufficient to effect compression. 
Dorendorff (Deut. med. Woch., Nov. 
31, 1902). 

Pain is one of the earliest and most 
constant symptoms of aortic aneurism. 
It was the first and most severe symp¬ 
toms in about half of the author’s 
cases. It is possible that it should be 
absent, though there may be dyspnea, 
cough, and cyanosis, and though the 
sac may perforate the chest wall or 
erode the spine. The most common 
situation for the pain is in the region 
of the heart itself, radiating to the 


neck, the shoulder, and back, and down 
the left arm or both arms. In some 
cases the abdominal pain is severe. 
Several distinct varieties of pain may 
be recognized in this disease: 1. At¬ 

tacks of true angina, having paroxysms 
of pain of maximum intensity, with 
radiation to the arm. 2. Sharp neu¬ 
ralgic pain due to pressure on the 
nerves, perhaps extending along the 
course of the nerves, and associated 
with herpes when the descending tho¬ 
racic aorta is implicated. It is similar 
in character to that which is caused by 
the pressure of pelvic tumors, and by 
disease of the vertebrae, and it may be 
paroxysmal in character. 3. Pain of a 
dull, boring character which is present 
when the chest wall or the spine is 
eroded by the aneurismal sac. This is 
the form of aneurismal pain which is 
most enduring and most severe. It is 
due to tension and stretching of fibrous 
and bony structures rather than to 
pressure upon nerve cords. 4. Pain re¬ 
ferred to the- nerves of thje arms or the 
skin in the precordial region or to the 
pectoral or sternomastoid muscles. 

One object of the writer’s paper was 
to narrate types of cases in which at¬ 
tacks of angina pectoris customarily 
precede the appearance of the aneurism 
for months or years. The paroxysms 
may not be in the least suggestive of 
aneurism, but they are associated with 
early structural changes in the wall of 
the aorta. In sclerosis of the aorta 
pain is not necessarily a symptom, the 
author having observed this fact in 
syphilitic patients. With lesions of 
arteries the pain may be the most in¬ 
tense, this being frequently observed in 
embolism, thrombosis, and the ligation 
of vessels. W. Osier (Med. Chronicle, 
May, 1906). 

With the exception of the rare cases 
in which there is trouble with swallow¬ 
ing, the early symptoms of aneurism, 
manifested by pressure, are usually 
either pain or disturbance with the re¬ 
spiratory apparatus. The latter may 
come either from pressure on the air 
passages or from pressure on the re¬ 
current laryngeal nerve. The symp¬ 
toms frequently simulate those of heart 


656 


ANEURISM (BABCOCK). 


disease, and their true meaning is 
learned partly by not finding a car¬ 
diac condition that will explain the 
symptoms, and partly by looking for 
and finding evidence of an aneurism. 

The picture of aortic aneurism in 
its earlier stages is not uniform, but 
varies widely with the position and 
size of the aneurism. There are no 
pathognomonic signs. Yet a careful 
physical examination and a careful 
consideration of the physical signs 
and symptoms should enable the de¬ 
tection of the existence of an aneu¬ 
rism of the ascending or transverse 
arch at a very early stage. 

An early positive diagnosis of 
aortic aneurism is obtainable only by 
the X-ray. Expansile pulsation is 
not constant. Abnormal dullness is 
a valuable sign when present. The 
most constant sign is systolic bruit, 
which was present in 11 of 19 cases. 
Tracheal tugging occurred in but 2 
cases. The earliest and most con¬ 
stant sjmiptoms were dyspnea and 
cough. Interference with passage of 
bismuth capsule the size of a quarter 
through esophagus was found pres¬ 
ent in every case tested (by X-rays). 
This is especially valuable in small 
aneurisms growing back from the 
transverse part of the arch, as it 
shows the esophageal obstruction be¬ 
fore dysphagia appears. Lange (Lan¬ 
cet-Clinic, Feb. 19, 1910). 

Only 2 phenomena were present in 
any considerable percentage of the 
cases, pain and dullness. The pain 
may be substernal, vertebral, may ex¬ 
tend down either arm or up the side 
of the neck to the occiput. The pain 
may be continuous or may occur as 
typical attacks of angina. Percus¬ 
sion seems to yield earlier informa¬ 
tion of an intrathoracic growth than 
any other method of physical exami¬ 
nation. Lemann (Amer. Jour. Med. 
Sci., Aug-, 1916). 

The writer found 17 cases of aneu¬ 
rism of the splenic artery mentioned 
in the literature. His own patient 
complained of dyspnea on exertion 
and edema. The abdomen was dis¬ 
tended and tympanitic, with a definite 


fluid wave and shifting dullness. The 
temperature varied from 98° to 103° 
F. Abdominal paracentesis was per¬ 
formed, the trocar being inserted in 
the midline about midway between 
the umbilicus and pubis. After 1200 
c.c. of slightly cloudy, reddish fluid 
had been withdrawn, the flow stopped. 
At the second puncture, inch lower 
down, the patient at once experienced 
a sharp pain in the abdomen, and the 
needle was withdrawn. Patient col¬ 
lapsed and died in 3 hours. The nec¬ 
ropsy showed a ruptured aneuris^m 
of the splenic artery, not due to 
trauma. Garland (Boston Med. and 
Surg. Jour., Apr. 14, 1921). 

The aneurism forms a smooth round 
^r oval enlargement in the course of an 
artery. It is not sensitive, unless in¬ 
flamed, is not adherent to the overlying 
^ skin, but may be associated with edema 
and venous congestion of the parts dis¬ 
tal to the tumor. The swelling has an 
expansive pulsation up to the time that 
a sufiflciently thick layer of clot forms 
within the sac to abolish this sign, so 
that the symptoms are at times divided 
into those of the expansile and those 
of the non-expansile stage. The artery 
distal to the aneurism gives a retarded 
and feeble pulse. The expansile pul¬ 
sation may be less marked and the 
tumor softer when the parts are ele¬ 
vated. The pulsation is diminished by 
pressure upon the main artery prox¬ 
imal to the aneurism, and in some cases 
the sac may then become softer and 
collapse. On auscultation a systolic or 
sometimes a double rough murmur or 
bruit is heard, loudest at the proximal 
pole. A shadow, emphasized if cal¬ 
careous deposits are present, may be 
shown by the fluoroscope or skiagraph. 

Subjective symptoms include pain 
from the stretching and compression of 
nerves and the arrest of the venous or 
lymphatic circulation. The pressure 
and erosion of bone, especially noticed 


ANEURISM (BABCOCK). 


657 


ill aneurisms of the aorta, cause the 
characteristic boring, so-called osteo¬ 
pathic pains which are usually more 
severe at night. 

In the skull the rushing sound and 
bruit, headache, and the evidences of 
cerebral pressure or irritation, such as 
choked disk, vomiting, dilated pupil, 
motor and sensory disturbances, and 
localizing nerve palsies, may be present. 

When an aneurism causes paralysis 
of the third nerve alone, it is uni¬ 
formly seated upon the trunk of the 
internal carotid, between the origins 
of the anterior and posterior com¬ 
municating arteries. When the aneu¬ 
rism involves the origin of the poste¬ 
rior cerebral artery, the paralysis of 
the third nerve is accompanied by 
paralysis of the corresponding facial. 
The only subjective symptoms (be¬ 
sides th^ diplopia) are pains in the 
head and constant noises upon the 
same side as the aneurism. These 
cases always end fatally. Pascheff 
(Archiv d’ophtal., Oct., 1910). 

In the neck the situation of the 
tumor, expansile pulsation, and the ef¬ 
fect upon the distal vessels are charac¬ 
teristic symptoms. 

In the chest the recurrent laryngeal 
nerve frequently is involved with the 
production of rasping voice, spasm or 
paralysis of the vocal cord, and brassy 
cough. Pressure upon the sympathetic 
may produce unilateral sweating and 
unilateral contraction or dilatation of 
the pupil as well as tachycardia. Pe¬ 
ripheral neuralgia may result from 
compression of the intercostals. Com¬ 
pression of the phrenic may cause 
dyspnea and hiccough, while pressure 
upon the esophagus may result in 
dysphagia. 

Although there is no one pathog¬ 
nomonic sign of thoracic aneurism, 
there are certain symptoms and signs 
taken together which make its exist- 

1—42 


encc practically certain. The pain, 
often slight and not complained of 
except after particular inquiry, is 
continuous, is situated near and to 
the left of the vertebral column, and 
tends to radiate to the shoulder, the 
left arm, and the neck. Examination 
of the chest shows no loss of reso¬ 
nance on the left side, but the reso¬ 
nance is not increased as in pneumo¬ 
thorax. At the same time the breath 
sounds are diminished over the left 
lung—this being due to partial com¬ 
pression of the left bronchus. The 
inspiratory sound is shorter over the 
left side, the first period of inspira¬ 
tion being inaudible and the air then 
entering with a rush, as though a 
valve had been opened. On inspec¬ 
tion, there is relative immobility of 
the left side of the chest, or in some 
cases there may even be definite re¬ 
traction. If the above signs be pres¬ 
ent, together with dyspnea on effort, 
in a patient whose general health is 
fairly good and who has no sign of 
malignant disease, the presumption 
of the existence of aneurism is 
strong. Inequality of the pupils is 
often an early symptom. Clement 
(Lyon med., March 31, 1907). 

In 40 cases of aortic aneurism in¬ 
vestigated at the Seamen’s Hospital, 
Greenwich, the blood-pressure on 
admission was invariably above nor¬ 
mal. A difference of 5 or 10 mm. 
Ilg. between the two arms was of 
little importance, but a marked differ¬ 
ence of from 15 to 20 mm. or so was 
strong evidence of the presence of 
aneurism. Mackinnon (Brit. Med. 
Jour., Oct. 4, 1913). 

Hemoptysis from perforated aortic 
aneurism was witnessed by the writer 
some 15 times owing to tracheal or 
bronchial perforation, all the cases 
being necessarily fatal. But with the 
diagnosis established, hemoptysis 
may not, however, mean that the 
aneurism has burst. It may be due 
to atheroma of the pulmonary ves¬ 
sels, or the aneurism itself, still in¬ 
tact, may cause a perforation into the 
pulmonary artery. Hampeln (Deut. 
med. Woch., May 1, 1913). 


658 


ANEURISM (BABCOCK). 


The various pulmonary lesions 
caused by or associated with aortic 
aneurism include collapse, bronchiec¬ 
tasis, chronic pneumonia, and, rarely, 
localized gangrenous areas around 
the bronchi. They are apt to re¬ 
semble pleuritic efifusion, malignant 
disease, cirrhosis, and phthisis very 
closely. In some cases tuberculosis 
develops in the lung, which is thus 
collapsed or affected with chronic 
pneumonia. Bramwell (Edinburgh 
Med. Jour., Feb., 1916). 

Tracheal tugging is often found in 
aneurism of the arch of the aorta, and 
is due to the transmission of the aneu- 
rismal pulsations to the left bronchus, 
and is detected by inclining the head 
and lifting the larynx and trachea by 
the finger and thumb caught under the 
hyoid bone. 

Two cases of aortic aneurism were 
observed by the writer which were 
mistaken for asthma, owing to ab¬ 
sence of tumor, pulsation, thrill and 
bruit. The diagnosis was made by 
inspection and confirmed by ront- 
genograms. S. Solis Cohen (Inter¬ 
state Med. Jour., Jan., 1912). 

Inanition may follow in the rare in¬ 
stances in which the thoracic duct is 
compressed. In thoracic aneurism the 
distal vessels show a retarded and re¬ 
duced pulsation, so that the pulse may 
be weak or even absent from one wrist. 

In examining for aneurism of the 
aorta, one should carefully percuss 
the area of dullness of the great ves¬ 
sels, note the conduction of the heart 
sounds in this area, examine both 
radial pulses simultaneously, examine 
for the tracheal tug, note all evi¬ 
dences obtained by inspection or pal¬ 
pation, note carefully all the ana¬ 
tomical relations of the aorta, and 
ever keep in mind the possibility of 
aneurism. Arnold (Amer. Jour. Med. 
Sci., Apr., 1908). 

In cases of thoracic aneurism, de¬ 
lay or increased retardation of one 
of the radial pulses does occur. The 
same delay may or may not be pres¬ 


ent in the case of the corresponding 
carotid pulse. If the idea, based on 
experimental physics, be correct, that 
delay of the pulse-wave is only pro¬ 
duced as the result of the wave pass¬ 
ing through the aneurism, then the 
phenomenon of delay should be of 
most important diagnostic aid in the 
localization of the aneurism. Digital 
examination is not a reliable test of 
the presence or absence of delay. 
The finger may miss the delay when 
present, and may diagnose it when 
absent. A more delicate instrument, 
such as the clinical polygraph, is 
necessary. Leonard Findlay (Prac¬ 
titioner, Dec., 1909). 

In 2 cases observed by the writer, 
the arteriovenous aneurism became 
transformed into an arterial form, 
and this retrogressed spontaneously 
and totally in 1 case, partially in the 
other. Chevrier (Presse med., Dec. 
19, 1918). 

Rupture is signalized by pain of sud¬ 
den onset with shock. 

Two cases of aneurism of the ab¬ 
dominal aorta apparently of arterio¬ 
sclerotic origin which ruptured into 
the duodenum. Marlow and Doubler 
(American Journal Med. Sci., April, 
1918). 

Series of cases illustrating the 
many directions which aortic aneu¬ 
risms may take in relation to other 
organs. In 1 case the perforation 
was external, through the sternum; in 
1 it was into the superior vena cava; 
in 1 it was into the left pleural cavity 
by way of the diaphragm; in 1 it was 
retroperitoneal; in 1 it was into the 
left pleural cavity by way of the left 
lung; in 2 it was into the left main 
bronchus; in 1 it was into the left 
ventricle; and in 1 it was into the 
pulmonary artery; 6 were therefore 
aneurisms which sprang from the 
arch of the aorta. Two were developed 
from thg abdominal aorta. Woolley 
(Amer. Jour, of Syphilis, Apr., 1917). 

As a result, the hemorrhage may 
escape externally through the skin, 
into the trachea, or into the alimentary 


ANEURISM (BABCOCK). 


659 


canal; if into the pericardium there are 
evidences of acute heart compression; 
if into the cavity of the thorax, of 
hematothorax; if into the muscular 
substance, the formation of a progress¬ 
ively enlarging tumor. The rupture 
may be immediately fatal, or the pa¬ 
tient may live for hours or for days, 
and repeated or continuous leakage may 
occur. Rarely does recovery follow 
after an aneurism of one of the great 
vessels of the trunk has ruptured, al¬ 
though the patient may survive for 
days or weeks. 

Case of abdominal aortic aneurism in 
a man aged 41 years in whom the 
writer observed several hyperesthetic 
cutaneous zones, as described by Head. 
Such zones are segmental regions of 
the body corresponding to the various 
viscera, exactly at the sensory inner¬ 
vation of the skin, as described by 
Sherrington, Starr, Kocher, and Thor- 
burn. Trophic disturbances occur in the 
skin in disease of the arteries, as, for 
example, in zoster. The points noted 
in the study of the present case in¬ 
cluded the belt-like distribution of the 
radiations of pain due to the abdominal 
aneurism, these pains dating many years 
before the development of the symp¬ 
toms. E. Cedrangolo (Ri forma medica. 
Mar. 23, 1907). 

COURSE. —Aneurisms tend to pro¬ 
gressively dilate and finally to rup¬ 
ture. In rare instances an aneurismal 
sac may remain stationary for many 
years, finally to again progressively 
dilate. In a third class spontaneous 
cure occurs by the coagulation of blood 
within the sac, which may completely 
consolidate it, with or without oblitera¬ 
tion of the arterial lumen. Any con¬ 
dition which interrupts or retards the 
circulation through the sac may favor 
this spontaneous cure. This termina¬ 
tion at times is followed by a fatal 
gangrene from obstruction of the col¬ 
lateral circulation. 


Plastic arteritis with thrombosis and 
obliteration of the artery may also lead 
to a cure. More frequently the aneu¬ 
rism progresses to rupture. The rup¬ 
ture may occur through the skin, mu¬ 
cous membrane, into a serous or syno¬ 
vial cavity or into the subcutaneous 
tissues, muscles, or fascial planes. 

There may be repeated moderate 
hemorrhages, one or several large hem¬ 
orrhages, or a rapid hemorrhage suffi¬ 
cient to cause almost instant death 
or a progressively increasing hemor¬ 
rhagic edema from a leaking aneurism. 
This may lead to gangrene. 

Suppuration of an aneurism occurs 
most frequently in the axillary region 
and usually results from the formation 
of an abscess adjacent to the sac. The 
sloughing of the sac wall may be fol¬ 
lowed by great hemorrhage as the ab¬ 
scess opens. Rarely does a plastic 
arteritis produce clotting and sponta¬ 
neous cure. 

DIFFERENTIAL DIAGNOSIS. 

—The expansile pulsation, bruit, and 
retardation of the distal pulse are 
fairly characteristic symptoms of 
aneurism. In a consolidated aneu¬ 
rism, or one in which the sac has been 
filled by clot, these signs may disap¬ 
pear. 

The history and presence of a firm 
mass in the wall of the blood-vessel are 
suggestive. Tumors and abscesses ly¬ 
ing upon large arteries may pulsate, 
but the expansile type of pulsation is 
absent. 

When the skin over an aneurism has 
become inflamed the condition may 
closely simulate an abscess, so that only 
by a careful study of the patient is a 
correct diagnosis finally to be made. 

Before the consolidation, compression 
of the main artery proximal to the 
aneurism may produce a characteristic 


660 


ANEURISM (BABCOCK). 


collapse of the sac, a cessation of pul¬ 
sation, and bruit, changes which cannot 
be produced in vascular sarcomas and 
other tumors which may simulate aneu¬ 
risms. 

In aneurisms of the thorax X-ray 
examinations are often diagnostic. 

In suspected aneurisms of the ab¬ 
dominal aorta loss or retardation of the 
femoral pulse should be especially 
looked for. The marked pulsation of 
the undilated aorta in thin persons 
should not be mistaken for aneurism. 

In determining the compressibility 
of the aneurismal sac the greatest gen¬ 
tleness must be employed. We have 
observed hemiplegia to promptly follow 
the examination and the palpation of 
a carotid aneurism for the dislodgment 
of particles of contained clot. 

TREATMENT. —Dietetic, hygi¬ 
enic, and medicinal measures have 
been used since antiquity with the ob¬ 
ject of slowing the circulation and so 
simulating coagulation that a clot 
would fill the sac. The ancient method 
of Valsalva included absolute physical 
and mental rest, a very limited diet, 
with the deprivation of fluid, and re¬ 
peated venesections continued until the 
patient was too weak to lift a hand. 

The more recent method of Tuff- 
nell’s was less severe, although rigor¬ 
ous; it consisted of a reduction in the 
diet and absolute rest in a horizontal 
position; 2 ounces of bread and butter 
are given for breakfast with 2 ounces 
of milk; 3 ounces of bread and butter 
with 4 ounces of water or claret for 
dinner; 2 ounces of bread and butter 
with 2 ounces of tea for supper. A fat 
diet has been advised by Powell, and 
the use of meats has been condemned. 

Cure by what was practically the 
Tufnell treatment. It consisted of as 
nearly absolute rest as possible, re¬ 


stricted diet for a week and later an 
■ordinary lish diet, no stimulation, 
and potassium iodide, 10 grains three 
times a day. The dose was quickly 
and steadily increased so that by the 
end of the third week 60 grains were 
being taken three times a day, with 
no ill effects at any time. As a local 
application to the swelling, collodion 
was painted all over the surface 
every night and morning. Instead of 
continuing his previous downward 
progress, he commenced to improve 
from almost the commencement of 
the treatment, and was discharged 
apparently cured in six weeks. 
Young (Lancet, Sept. 22, 1906). 

Drugs are employed to reduce the 
cardiac frequency, to diminish arte¬ 
rial tension, and increase the coagula¬ 
bility of the blood. Potassium iodide 
has been considered to be the most 
valuable drug. Ten grains three times 
a day may be increased until 40, 60, 
or 200 grains three times daily are 
administered, according to the degree 
of tolerance. It is especially valuable 
in syphilitic patients. 

In aneurism of the aorta the writer 
urges antisyphilitic treatment, be¬ 
cause syphilis is the fundamental dis¬ 
ease in the majority of cases. The 
best routine procedure is an intra¬ 
venous injection of 0.2 Gm. (3 grains) 
salvarsan every week until three 
doses have been given; then, if indi¬ 
cated, it may be repeated in 0.6-Gm. 
(10 grain) doses a month or 2 apart. 
In the interim intramuscular injec¬ 
tions of mercury about twice a week 
should be given in conjunction with 
potassium iodide, as this treatment 
often is efficacious and is followed 
by marked improvement. Selian 
Neuhof (Amer. Jour. Med. Sci., May 
1916). 

To increase the coagulability of the 
blood in the treatment of saccular 
aneurisms the subcutaneous injec¬ 
tions of gelatin, were first recom¬ 
mended by Lancereaux and Paulesco. 


ANEURISM (BABCOCK). 


661 


One or 2 Gm. of purest gelatin are 
dissolved in 100 c.c. of decinormal salt 
solution, and sterilized by heating to 
the boiling point for one-half hour on 
five successive days. Before use the 
gelatin is warmed to the temperature 
of the body and 100 c.c. injected under 
the abdominal skin every two, three, or 
four days. 

Plea for the use of injections of 
gelatin in aneurism of the aorta. The 
danger of tetanus is removed if the 
gelatin is properly sterilized and no 
disagreeable effects are noticed by 
the patients. Lancereaux (Revue de 
therap., No. 13, 190(>). 

Case of large traumatic aneurism 
occupying the lower half of the left 
popliteal space, and extending down¬ 
ward to a line about 6 inches below 
the knee-joint. After a prolonged 
and careful treatment by rest and 
flexion of the leg, which proved un¬ 
successful, the author tried repeated 
subcutaneous injections of sterilized 
gelatin serum. Seven injections were 
made, the intervals varying from 
seven to twenty days. The last injec¬ 
tion was followed after an interval of 
about ten days by co*mplete cure. Le 
Dentu (Bull, et mem. de la soc. de cbir. 
de Paris, No. 10, 1905). 

Treatment of 40 cases showed that 
potassium iodide does not reduce the 
blood-pressure, although it often re¬ 
lieves pain. This can also be ob¬ 
tained by other means, notably by 
the injection of sterilized solution of 
gelatin. Gelatin does not reduce the 
blood-pressure, but in Rankin’s and 
personal cases there was very marked 
relief of pain in almost every in¬ 
stance where such symptom was a 
prominent feature. Mackinnon (Brit. 
Med. Jour., Oct. 4, 1913). 

Case of aneurism of the ascending 
portion of the aorta,'’with distressing 
symptoms, in which, after intraven¬ 
ous injections of mercury cyanide 
and gelatin had proved useless, per¬ 
cussion of the spine of the seventh 
cervical vertebra according to Ab¬ 
rams’s method (see page 667) was 


tried, with signal success. The per¬ 
cussion was practised daily for live 
minutes. After eight sittings the pa¬ 
tient was able to walk five miles 
without distress, and resumed his 
work as a baker. R. Houlie (Bull, et 
mem. de la Soc. de Med. de Paris, 
May 8, 1914). 

In a certain percentage of cases, 
according to the writer, it may be 
possible to overcome the effects of an 
aneurism and induce a clinical cure 
by the treatment consisting chiefly in 
strict bed rest, reduction of the diet 
to 4 small meals a day without fluids; 
only 300 c.c, of fluids are permitted 
in the 24 hours. Venesection may be 
necessary and ice to the region of 
the aneurism, with local injections of 
ergot around the aneurism and injec¬ 
tion of gelatin into the buttocks, with 
potassium iodide internally. Mara- 
gliano (Gaz. degli ospedali, Jan. 31, 
1915). 

A medical cure of an aneurism in 
the middle portion of the right supra¬ 
clavicular region was obtained by the 
writer. The man was kept abso¬ 
lutely quiet in bed, on a milk-vege¬ 
table diet, without much liquid, and 
he was given once a week for 20 
weeks, a subcutaneous injection in 
the flank of 60 or 40 c.c. (2 or \% 
ounces) of a 2 per cent, solution of 
gelatinized serum. As the Wasser- 
mann reaction was positive, mer¬ 
curial treatment was given at the 
same time. Improvement was rapid 
and pronounced. The aneurism sub¬ 
sided to a clinical cure. T, Castel¬ 
lano (Prensa Medica, Feb. 10, 1918). 

Several cures have been reported 
from the use of gelatin, but in other 
instances undesirable thrombi have 
formed in the larger veins, while teta¬ 
nus has followed the use of imperfectly 
sterilized gelatin. Should the clot 
which forms in the aneurismal sac 
soften and be absorbed, the gelatin in¬ 
jections may be repeated with a possi¬ 
bility of good effect. 

The internal administration of cal¬ 
cium chloride and the subcutaneous 


662 


ANEURISM (BABCOCK). 


injection of horse serum have also 
been used to increase the coagulability 
of the blood. 

Case of aortic aneurism in which all 
the symptoms, except a slight headache, 
had disappeared as a result of the ad¬ 
ministration of calcium chloride for 
about two months. The calcium chlo¬ 
ride was given three times daily. The 
aneurism was clearly visible under the 
X-ray. Ambrose (Jour. Amer. Med. 
Assoc., Oct. 31, 1908). 

Arterial Compression.—The object 
of this method is to so slow the blood- 
current within the sac that a coagulum 
may form. The pressure may be prox¬ 
imal to the aneurism and be carried out 
by means of a pad, tourniquet, or the 
pressure of the thumbs of assistants 
acting in relay. The pressure of the 
thumb is reinforced by a 6-pound 
weight, and before the thumb of one 
assistant is removed that of another is 
properly placed. Each assistant serves 
for fifteen or twenty minutes, and the 
treatment is continued for from, twenty- 
four to seventy-two hours. The method 
by compression is painful and when in¬ 
strumental may cause sloughing or 
gangrene. The digital compression re¬ 
quires many assistants and is trouble¬ 
some, but not so apt to cause sloughing. 
The compression occasionally cures, 
but often if the clot is deposited it is 
dissipated before organization has oc¬ 
curred. 

Three cases of aneurism followed, 

2 for eight years and 1 for four years, 
in 2 of which permanent cure has re¬ 
sulted from treatment based on a 
reduction of vascular tension below the 
normal. The treatment consists in 
keeping the patient at rest in bed and 
in prescribing a diet from which soups 
containing an excess of fat; meats, es¬ 
pecially those cooked rare; game, fish, 
cheese, salted foods, tea, coffee, spirits, 
heavy beers, and an excess of wine 
are eliminated. Tobacco is also for¬ 
bidden. Drugs, such as nitroglycerin 


and sodium nitrite, were administered. 
The iodides have been overrated in 
this connection. In syphilitic aneu¬ 
risms mercurial injections are dan¬ 
gerous on account of their liability 
to affect the kidneys, and, as a conse¬ 
quence, to cause increased arterial ten¬ 
sion. The milk diet in connection 
with theobromine, which assists in 
eliminating vasoconstrictor poisons, 
is very helpful in reducing vascular 
tension. H. Huchard (Jour, des 
praticiens, Nu. 20, p. 307, 1906). 

Forced flexion of the elbow and 
knee, the part being held by a bandage 
with the pad at the flexure, has been 
employed for small aneurisms of the 
extremities. The position is uncom¬ 
fortable and the method of little ad¬ 
vantage over other methods of com¬ 
pression. 

The isolation of a mass of blood 
within the aneurismal sac by the ap¬ 
plication of an Esmarch bandage be¬ 
low and above the aneurismal sac, 
while efficient in causing clotting, has 
led to gangrene of the extremity, and 
the method has been abandoned. It 
has been advised that an Esmarch 
bandage be applied for one and one- 
half hours and then removed, with con¬ 
tinuous light compression of the artery 
above the aneurism for several days. 
Apart from the danger of compression, 
another danger of these methods is in 
the completeness of the coagulation, 
which may extend into the collateral 
vessels and so destroy their function 
that gangrene follows. 

Arterial Ligature.—Ligature of the 
main artery just above the sac is espe¬ 
cially efficient in interrupting the circu¬ 
lation. This is Anel’s operation, but 
was modified by John Hunter, who 
placed the ligature at a distance above 
the sac, where he supposed that the 
arterial walls were healthier. Anel’s 
operation is now preferred to Hunter’s. 


ANEURISM (BABCOCK). 


663 


The most important part of the 
new surgical work with blood-ves¬ 
sels, especially with aneurism, de¬ 
pends upon the similarity of the se¬ 
rous coat of blood-vessels to the 
peritoneum. Like the latter, the 
former throw out lymph for pur¬ 
poses of repair. Irritated surfaces 
in apposition adhere. Torsion of 
blood-vessels also causes quick plas¬ 
tic occlusion so that arteries of the third 
class may be thus treated in place 
of by ligation. Aneurism treated by 
digital pressure, by the introduction 
of coils of wire, or by electric needles 
causes exudation of lymph from the 
serous coats, followed by adhesion of 
apposed surfaces. The new work in 
suturing blood-vessels depends for its 
safety upon the prompt plastic repair 
of the serous coats. Morris (Annals 
of Surg., July, 1908). 

According to the writer, it has 
been found by English surgeons, 
contrary to the commonly accepted 
ideas, that in many cases simultane¬ 
ous ligation of vein and artery may 
be safer as regards both life and 
avoidance of gangrene than ligation 
of the artery alone. H. S. Valentine 
(Trans. Mo. State Med. Assoc.; Jour. 
Amer. Med. Assoc., May 1, 1920). 

When on account of anatomical con¬ 
ditions the ligature cannot be placed 
above the sac the method of distal li¬ 
gation, such as Basedow’s, in which 
the main vessel is ligatured, or War- 
drop’s, in which one or more of the 
chief branches is secured as by ligation 
of the right subclavian for aneurism 
of the innominate artery, may be 
tried. Rarely are they efficient. 

A successful case (the ninth with 
recovery) of ligation of the innom¬ 
inate artery. The patient was a 
colored man aged 27 suffering from 
subclavian aneurism; the innominate 
only was tied with a largest-sized 
braided silk ligature in a “granny” 
knot drawn just tightly enough to 
approximate the vessel walls, but not 
to crush its coats. The ligature 
came away 51 days after the opera¬ 


tion while the wound was being 
dressed; the recovery was good prac¬ 
tically in 20 days. Burns (Jour. 
Amer. Med. Assoc., Nov. 14, 1908). 

In aneurisms at the root of the 
thigh the writer resorts to prelimin¬ 
ary elastic compression with the 
Esmarch band or by Momburg’s 
method. The blood flow can always 
be arrested beforehand by passing a 
strand of catgut beneath the vessels 
and having an assistant exert mod¬ 
erate upward traction on it. In none 
of his cases, whether of spontaneous 
or traumatic aneurism, did gangrene 
follow quadruple ligation of the fem¬ 
oral artery and vein above and below 
the aneurism, with extirpation of the 
latter. Even in a large pathological 
aneurism, with removal of 17 centi¬ 
meters of the external iliac artery 
and of the femoral trunk, superficial 
as well as deep, not the least circu¬ 
latory difficulty followed—probably 
in this case because the aneurism was 
of about 10 years’ standing. Much 
delay in operating on aneurisms, es¬ 
pecially in war practice, is inadvisable, 
for as time passes the aneurism ex¬ 
tends, and increasingly firm adhesions 
with the collateral veins, nerves, and 
neighboring organs or tissues become 
established, rendering dissection dif¬ 
ficult. Potherat (Presse med., June 
21, 1917). 

The late war afforded much ex¬ 
perience with traumatic aneurisms. 
The practical conclusion from dis¬ 
cussions and statistics, as expressed 
by the writers, is that ligation and 
resection of the aneurism constitute 
the safest and best treatment in the 
majority of cases. Only under 
exceptionally favorable conditions 
should end-to-end suture be con¬ 
sidered, though this is sometimes the 
only means to save the limbs. Len- 
ger, Strassen and Vonsken (Arch. 
Med. Beiges, Aug., 1920). 

Dix’s Operation.—The artery is ex¬ 
posed and encircled by a strand of 
silver wire. The ends of the wire are 
brought through the tissues to one side 
of the wound, and are twisted over a 


664 


ANEURISM (BABCOCK). 


Split cork until pulsation ceases in the 
aneurism. Later slight pulsation re¬ 
turns to the sac, and after two or three 
days the wire is tightened by placing 
wedges under the loop. About the fifth 
or sixth day the wire is cut and re¬ 
moved. 

Excision of the Sac and Implanta¬ 
tion.—The interposition of a segment 
of an adjacent vein has also been tried, 
but the procedure has rarely been suc¬ 
cessful. 

Removal or Obliteration of the Sac. 
—The ancient method of Antyllus, in 
which the sac was dissected out or 
opened and packed, has been suc¬ 
ceeded by the modern obliterative 
method of Matas. In this operation 
the patient is anesthetized, a tourniquet 
applied, the sac is opened by a longi¬ 
tudinal incision, emptied, and the mouth 
of each vessel is exposed within the 
sac and sutured from the inside by 
separate silk or chromicized catgut 
sutures. The redundant walls of the 
sac are then so enfolded and sutured as 
to form a solid pad under the skin. The 
advantage of this method lies in the fact 
that the sac is not loosened from the 
adjacent tissues, and, therefore, there 
is little risk of injuring adjacent col¬ 
lateral nerves and veins. 

Matas’s method combines the ad¬ 
vantages of ligation and excision, 
while at the same time it is easier, 
safer, and may be more conservative. 
It is suitable both in the fusiform and 
sacculated types of the disease. After 
applying a constrictor above the site of 
the disease, if in a limb, or temporarily 
ligating the proximal and distal trunks, 
if the carotid is the vessel at fault, the 
operator cuts into the sac, thoroughly 
removes the contained clots, rubs the 
serosa with gauze, and proceeds to in¬ 
sert sutures. The sutures, preferably 
catgut, are first applied to the openings 
of all vessels entering or leaving the 
sac; then the deeper portions of the 


sac are closed by two rows of contin¬ 
uous Lembert sutures. The plastic con¬ 
strictor is now removed, and if any 
blood escapes one or two points of 
suture are inserted to control this. The 
next step consists in folding the excess 
of sac wall on itself, and in so doing 
inverting the edges of the skin wound. 
The operation thus performed has been 
very successful, and in some cases of 
sacculated aneurism the circulation may 
be re-established through the repaired 
vessel. Binnie (Jour. Amer. Med. 
Assoc., June 25, 1904). 

Results of endoaneurismorrhaphy 
(the writer’s method) in 85 operations 
by 52 surgeons up to the present 
date. The legitimate mortality of the 
operation itself was 2.3 per cent.; of 
secondary hemorrhage, 2.3 per cent.; 
of gangrene, 4.6 per cent. Eliminat¬ 
ing 3 of the gangrene cases in which 
there was simultaneous injury and 
ligation of veins or secondary ligature 
of an artery, the percentage of this 
accident is 1.1 only. The total of post¬ 
operative deaths from all causes was 
7 to 78 recoveries. The percentage 
of relapses, which occurred only in 
the reconstructive operations (4 in 
13, or 28 per cent.), was only 4.7 per 
cent, to the total. The author be¬ 
lieves that the fundamental principle 
on which the operation is based, viz., 
that the endothelial lining of the vas¬ 
cular system which is continued in 
the aneurismal sac is analogous in its 
pathological behaviour to the reac¬ 
tions and reparative processes which 
occur in the endothelial surfaces of 
the other serosa, such as the peri¬ 
toneum and the pleura, has been ab¬ 
solutely confirmed by the experience 
in these 85 cases. They have also dis¬ 
proved Scarpe’s law that complete 
obliteration of the vessel is an essen¬ 
tial to the cure, which result is also 
supported by the facts of the suture 
and repair of arteries. An important 
point of the technique is the prophy¬ 
lactic hemostasis, which must be 
made absolute, and the problem in¬ 
creases in complexity and difficulty 
the higher the operation, and the 
writer mentions the method and ap- 


ANEURISM (BABCOCK). 


665 


pliances for this purpose. Experi¬ 
ence demonstrates that in all sacci¬ 
form aneurisms with a single orifice 
of communication the closure of this 
orifice by suture without interfering 
with the lumen or the capacity of 
the vessel is to be looked on as ob- 
ligator}^ The indication for the re¬ 
constructive operation, however, is 
fusiform aneurism with separate ori¬ 
fices of entrance and exit. In the 
vast majority of cases of aneurism 
of the extremities the simple oblitera¬ 
tive procedure proved satisfactory. 
It gives a cure with less risk to distal 
parts than ligature or extirpation. In¬ 
dications in any given case will not 
be entirely satisfactory until we have 
a sure clinical proof of the adequacy 
of the collateral circulation. Korot- 
kow’s method of testing the most 
peripheral blood-pressure may be the 
proper solution. R. Matas (Jour. 
Amer. Med. Assoc., Nov. 14, 1908). 

The advantages of Matas’s endo- 
aneurismorrhaphy are as follows: It 
is more radical in its effects than liga¬ 
ture and extirpation; it is free from 
risk of injury; it is only exceptionally 
followed by gangrene; it does not in¬ 
terfere with the collateral circulation; 
it prevents any danger of injury of 
a vein, and is applicable to cases in 
which extirpation is no longer pos¬ 
sible. For suture chromicized catgut 
or fine silk is employed. The method 
is chiefly indicated in cases in which 
provisional hemostasis can be carried 
out and where the aneurismal sac is 
accessible. Altogether 149 cases have 
been reported, in 131 of which the 
lower extremity was affected. Among 
the last 64 cases there have been no 
deaths, no recurrences or secondary 
bleeding, and only one instance of 
gangrene. Gardner (Gaz. d. Hop., 
No. 118, 1910). 

A second method is Matas’s con¬ 
servative endoaneurismorrhaphy, to 
be used for sacculated aneurisms open¬ 
ing" by a narrow mouth into the main 
vessel. This opening is sutured from 
the inside of the sac and the wound 


reinforced, pleating and suturing the 
overlying sac. In reconstructive endo¬ 
aneurismorrhaphy an attempt is made 
to restore the normal lumen of the 
artery in a fusiform aneurism. A rub¬ 
ber tube may be temporarily intro¬ 
duced as a guide between the afferent 
and efferent mouth of the sac, and the 
walls of the sac so sutured as to re¬ 
store a canal having the lumen similar 
to that of the adjacent artery. This 
line of suture is likewise to be rein¬ 
forced by pleating and suturing the 
redundant walls of the sac. 

Report of a case of reconstructive 
aneurismorrhaphy in the third part 
of the axillary artery, the aneurism 
having been the result of a gunshot 
wound received 2 years previously. 
The aneurism and a portion of the 
axillary artery both above and below 
were dissected free and Crile artery 
clamps applied above and below the 
tumor. The aneurismal sac was then 
defined up to its point of origin from 
the artery and opened by a longi¬ 
tudinal incision. At the junction of 
vessel and sac was a ring of almost 
cartilaginous density. The sac was 
cut away so that only a thin rim 
around the neck was left. With a 
non-cutting fine needle a continuous 
suture was introduced, beginning 
above and finishing below the open¬ 
ing and passing through the arterial 
wall immediately adjoining the thick 
ring. Mattress sutures of fine silk 
were used. A second stronger silk 
suture was then introduced, the 
needle traversing the artery wall on 
either side and returning similarly 
through the rim of the sac, thus em¬ 
bracing the hard ring and securing 
apposition of its opposite side. Re¬ 
moval of the clamps revealed no ooz¬ 
ing. A fascia lata graft was fixed as 
a collar about the vessel to diminish 
the strain on the suture line. Three 
months later there was no sign of 
yielding and the brachial pulses were 
equal. C. J. Marshall (Brit. Med. 
Jour., i, 379, 1921). 


666 


ANEURISM (BABCOCK). 


Temporary partial obliteration of 
the main artery by use of metallic 
rings or clips; Halstead and others 
have devised rings or clips composed 
of aluminum or other metal which may 
be applied to an arterial trunk in such 
a manner that the lumen in the vessel 
is reduced or obliterated. By reducing 
the lumen the current in the artery and 
sac distal to the ring may be so slowed 
as to favor curative coagulation, and 
if properly applied it has been found 
that these rings are well tolerated by 
the arterial wall, and have not the same 
tendency to ulcerate into the lumen of 
the vessel as a ligature. 

The application of a ligature is not 
feasible in the case of the aorta, for 
in every case in which a ligature has 
been employed the patient has died, if 
not from the immediate danger from 
the operation, then some days or weeks 
later from secondary hemorrhage due 
to the ligature cutting its way through 
the wall of the artery. 

Macewen’s Acupuncture. — This 
method aims to scarify the lining of 
the sac so that the granulations form 
upon which the blood may coagulate. 
One or more long fine-silk needles are 
thrust into the aneurism so that their 
points just touch the opposite wall. The 
pulsatile movements of the sac wall 
cause the needle-points to scratch the 
lining of the sac. The needles are left 
in place some hours, their position then 
is so changed that as large an area as 
possible of the lining will be abraded. 
The method is of very limited value. 

Electrolysis increases the efficiency 
of Macewen’s method. Insulated nee¬ 
dles are passed and a galvanic current 
from 20 to 30 milliamperes. Needles 
should be permitted to touch the oppo¬ 
site wall of the sac so as to produce 
the delicate abrasion as in acupuncture. 


Report of 2 cases of thoracic aneu¬ 
rism upon which the Moore-Corradi 
operation of wiring with electrolysis 
had been performed over 4 years pre¬ 
viously. In the first, 17 feet of No. 
29 gold “clasp” wire had been used 
and in the second 22^2 feet. Active 
antisyphilitic treatment was insti¬ 
tuted in both patients with great 
benefit. The best result is obtained 
when the wire is so introduced as to 
bring it as much as possible in con¬ 
tact with the wall of the aneurism. 
This permits the clot produced by 
the electrolysis to come in contact 
with vitalized tissue from which it 
can become organized. W. C. Lusk 
(Annals of Surg., Ixiv, 680, 1916). 

Moore’s method consists in the use 
of a delicate wire so tempered as to 
coil within the sac, where it is permitted 
to remain permanently. A small, hol¬ 
low needle is introduced into the sac 
until the blood flows and from 5 
to 20 feet of wire, according to the 
size of the sac, passed through the 
needle. The end of the wire is then 
pushed through the needle or cut close 
to the skin and made to imbed itself. 

The Moore-Corradi method con¬ 
sists in passing the current from 
20 to 80 milliamperes through the coil 
of wire which has been introduced into 
the sac. A wire of fine drawn gold is 
preferred, and from 5 to 20 feet intro¬ 
duced, as in the Moore method. The 
current is permitted to flow about one 
hour, negative pole being connected 
with a pad upon the patient’s abdomen 
or back. The wire is permitted to re¬ 
main permanently within the sac. 

Aneurism of the left subclavian 
artery in which 20 feet of gold wire 
were introduced into the sac through a 
hollow needle, and a galvanic current, 
gradually increasing from 1 to 80 milli¬ 
amperes, was employed for about one 
hundred and ten minutes. The pulsa¬ 
tion and size of the tumor temporarily 
decreased and afterward increased; and 


ANEURISM (BABCOCK). 


667 


death occurred on the twentieth day 
after operation, due to exhaustion 
and pressure thrombosis. Daland 
(Penna. Med. Jour., Dec., 1903). 

Three further cases of sacculated 
aneurism of the aorta successfully 
treated by wiring and electrolysis. 
The second case was too advanced for 
anything more than palliation. One 
of the most important effects is the 
relief of pain. This is usually imme¬ 
diate. H. A. Hare (Jour. Amer. Med. 
Assoc., Ixxvi, 587, 1921). 

These methods have chiefly been em¬ 
ployed for aneurisms of the thoracic 
aorta. Occasionally cures are reported, 
but failures are frequent and fatal acci¬ 
dents have occurred. It is obvious that 
even in so-called cures the patient’s 
ultimate condition is not a normal one. 
Sterilized horsehair, silk, and catgut 
have also been tried, but with question¬ 
able benefit. 

A recent addition to the methods of 
treatment is that of Abrams, which, 
though qualified by him as palliative, 
seems to have produced lasting bene¬ 
ficial efifects in a large number (40) of 
his cases. It consists of repeated con¬ 
cussions over the seventh cervical 
vertebra, which are thought by 
Abrams to cause, through the vaso¬ 
motor system, contraction of the 
diseased vascular area. Confirmatory 
evidence is still too scant to warrant 
any opinion as to the actual value of 
this method. 

A. Abrams, of San Francisco, claims 
that the subsidiary center of the vaso¬ 
constrictor nerves of the aorta is located 
in the spinal cord in proximity to the 
spinous process of the seventh cervical 
vertebra, and that by stimulation of the 
center in question by concussion the 
normal as well as the abnormal aorta 
may be brought to contraction. Ample 
evidence is furnished of the latter fact 
in his work on spondylotherapy. The 
method, in brief, which he suggests in 
the treatment of aortic aneurism con¬ 


sists in concussion of the spinous 
process of the seventh cervical verte¬ 
bra. He deprecates the employment 
of the conventional vibrating appa¬ 
ratus. The vibratory apparatus which 
the physician must employ is one 
giving the percussion stroke. All 
other motions, such as oscillations, 
shaking, and friction, interfere with 
results. In the absence of a suitable 
apparatus, a pleximeter (a strip of 
linoleum or thick rubber) and a 
hammer, to the end of which is fixed 
a piece of hard rubber, are employed. 
The pleximeter is applied to the 
seventh cervical spine and is struck 
a series of rapid and moderate blows 
by the hammer. The daily seances, 
according to results, may last from five 
to fifteen minutes, but during the seance 
the treatment must be interrupted from 
time to time to avoid irritations of the 
skin. 

The results of Abrams’s method are 
usually immediate, great relief follow¬ 
ing a few seances. When the writer 
first encountered the monograph of the 
latter on the subject, he was rather 
skeptical, although Abrams anticipates 
such criticism in his book by observing 
that any merit attached to his method 
may be obscured by its simplicity. 

The writer presents the history of a 
personal case suffering from aneurism 
of the thoracic aorta which was treated 
successfully by the “concussion method” 
of Abrams. The aneurism had per¬ 
forated the chest wall. Within one 
week all the symptoms had disappeared, 
and fourteen months after the patient’s 
discharge he was as well as when dis¬ 
missed. L. St. John Hely (Amer. Jour, 
of Physiol. Therap., July, 1910). 

Case of aneurism of the thoracic 
aorta treated by Abrams’s method. 
After the first daily seance of concus¬ 
sion, lasting ten minutes, the systolic 
murmur over the aorta almost disap¬ 
peared. Three days later the aneuris- 
mal dullness measured transversely 2.6 
cm. After two more days the aneurism 
measured 2 cm. and the patient’s weight 
was 123 pounds, an increase of 5 
pounds. Two days later - there was 
absolutely no dullness over the site of 


668 


ANEURISM (BABCOCK). 


the aneurism, the pains in the chest 
were gone, expectoration was re¬ 
duced about 50 per cent., but the 
cough continued with less frequency 
and severity. After about two 
months the patient’s weight was 135 
pounds. He had absolutely no 
symptom beyond an occasional slight 
cough. Turnbull (Med. Record, 
Sept. 9, 1911). 

Report of a case of aneurism of the 
thoracic aorta treated successfully by 
Abrams’s method. There was no 
X-ray verification of the condition in 
this case, but the physical signs re¬ 
specting the aneurism and the re¬ 
sults of treatment were absolutely 
positive and unmistakable. Boyd (N. 
Y. Med. Jour., Oct. 21, 1911). 
ARTERIOVENOUS ANEU¬ 
RISM. —These conditions, termed by 
Hunter aneurism by anastomosis, are 
characterized by an arteriovenous fis¬ 
tula. They may be divided into tvv^o 
chief forms:— 

(a) Aneurismal varix is character¬ 
ized by the direct communication of the 
artery with the vein. The blood-pres¬ 
sure is much higher in the artery; the 
arterial flow is forced into the vein, 
which becomes thickened, dilated, sac¬ 
culated, and tortuous. The condition is 
usually due to the incised wound involv¬ 
ing the contiguous walls of an artery 
and vein, and gunshot wounds. Occa¬ 
sionally they result from contusions 
without external wound, and may even 
develop spontaneously. In the older 
days the common cause was phlebot¬ 
omy. In order of frequency the bra¬ 
chial, femoral, popliteal, carotid, tem¬ 
poral, subclavian, and axillary arteries 
are involved. Instances are recorded 
in which the condition has spontane¬ 
ously occurred in connection with the 
abdominal and thoracic aorta, and after 
gunshot wounds of the head a fistula 
may form between the cavernous sinus 
and internal carotid artery. 


(b) Varicose Aneurism. —The vein 
communicates with the artery through 
the medium of an aneurismal sac. This 
usually develops from a traumatic aneu¬ 
rism which becomes adherent to an 
adjacent vein and finally opens into it. 
Both the artery and the vein may be 
injured simultaneously and an interme¬ 
diate blood-clot first form, the sac 
finally replacing the area occupied by 
the blood-clot. Such an aneurism may 
form at the ends of the divided vessels 
in an amputation stump. 

An arteriovenous aneurism with an 
arterial sac, such as that developed 
from the erosion of a true aneurism 
through the wall of an adjacent vein, is 
rare, and has been classified as a third 
variety of arteriovenous aneurism. 

Symptoms. —A marked pulsation 
which is communicated widely to the 
communicating veins is present and 
usually associated with a loud, whistling 
bruit. The bruit is both systolic and 
diastolic. The thrill may be palpable. 
The interference with the normal circu¬ 
lation in the vein may produce stagna¬ 
tion, local cyanosis, pigmentation, ec¬ 
zema, elephantiasis, muscular atrophy, 
ulceration, rarely gangrene. The pres¬ 
sure upon the nerves may result in 
paresthesia or paralysis. 

Among 42 cases of traumatic arte¬ 
riovenous aneurism observed by the 
writer in the Serbian army in 4 years, 
all operated on by him, 24 were of 
the direct type, artery and vein being 
in immediate communication. The 
common carotid artery was involved 
in 3 instances; the subclavian in 1; 
the brachial, 2; external iliac, 3; fem¬ 
oral, 13; and popliteal, 2. Often no 
hematoma around the affected ves¬ 
sels was found. Symptoms generally 
began only a few days and sometimes 
1 or 2 weeks after the injury, the 
most characteristic sign being an 
audible thrill originating at the point 


ANEURISM (BABCOCK). 


669 


of communication of the vessels and 
transmitted centrifugally along the 
artery and centripetally along the 
vein. At operation, especially in 
cases of external iliac or femoral in¬ 
volvement, a pronounced dilatation 
of the vein at and above the point 
of communication was noticed; like¬ 
wise, a narrowing of the arterial 
trunk below this point. Thus, a part 
of the blood brought by the artery, 
entering the vein, is transmitted by 
the latter, not in a peripheral, but in 
a central direction, toward the heart. 
The centripetal transmission of the 
thrill along the vein and the ab¬ 
sence of peripheral varicosities are 
thus accounted for in these cases of 
direct arteriovenous aneurism. Soub- 
botitch (Bull, de TAcad. de med,. 
May 30, 1916). 

Treatment.—The treatment of ar¬ 
teriovenous aneurism is usually op¬ 
erative, as the disease is usually per¬ 
sistent and progressive. The artery 
may be clamped above and below the 
opening and the opening in the artery 
and vein closed by arterial suture. 
Where a thoracic aneurism is present 
the sac may be split and the communi¬ 
cating opening sutured from within the 
sac, as in Matas’s aneurismorrhaphy. In 
some cases it may be necessary to ligate 
the artery above and below the point of 
communication. As a rule, the vein 
should not be ligatured. 

In small traumatic aneurisms in 
which the distended inner coat of the 
vessel bulged through the external 
coats we have found it possible to re¬ 
duce the hernia-like protrusion and to 
reunite the median adventitia by fine 
silk sutures, which reinforce the 
union by suturing adjacent connec¬ 
tive tissue to the arterial wall. 

Analysis of 161 cases of arterio¬ 
venous aneurisms published since 
1889. The femoral was involved in 
■ 80 and the popliteal in 35 cases. 
Much better results are obtainable, as 


a rule, from operating directly on 
the sac than from ligatures. The 
main drawback to a complete cure 
is the frequent coexistence of nerv¬ 
ous lesions complicating the aneu¬ 
rism, which are generally solely re¬ 
sponsible for the postoperative dis¬ 
turbances. Only when direct action 
on the sac is impossible should liga¬ 
tures he given the preference. Re¬ 
moval of the sac offers the same ad¬ 
vantages over incision for the arte¬ 
riovenous as for the arterial aneu¬ 
risms. Monod and Vanverts (Revue 
de chir., Oct., 1910). 

In none of 15 cases of traumatic 
aneurism seen by the writer was he 
satisfied with simple ligature of the 
vessels, and the accompanying dan¬ 
ger of relapse. The injuries in all 
were too complex and extensive to 
make it possible to carry out lateral 
suture in order to preserve the per¬ 
meability of the arterial trunks. An 
essential condition for the perform¬ 
ance of extirpation of arteriovenous 
aneurisms is to have a wide opening 
on to the aneurism; thus, for aneu¬ 
risms in the axilla the pectoralis 
major was divided vertically; for 
aneurisms in the carotid region the 
sterno-mastoid was divided horizon¬ 
tally. These large divisions of mus¬ 
cle do not give rise to any serious 
functional trouble later if the divided 
ends are accurately sutured together 
at the end of the operation. Auvray 
(Bull, et mem. de la Soc. de Chir. de 
Paris, Apr. 20, 1915). 

In 102 operations for aneurism due 
to war injuries the best treatment 
was found by the writer to be suture 
of the artery; it was performed in 74 
cases; in most of the cases the suture 
was along the axis of the vessel; in 
only 3 cases was transverse suture 
performed. In arterial aneurism lat¬ 
eral suture was a simple operation. 
This was not the operation for arte¬ 
riovenous aneurism. In 36 cases the 
wounded piece of artery was resected 
and the ends sutured circularly. 
Transplantation of a piece of vein to 
fill in the gap was not found neces¬ 
sary. Circular suture was easily per- 


670 


ANGINA PECTORIS (VICKERY). 


formed, even on the larger arteries; 
intima was applied to intima and a 
continuous suture inserted. Small 
arteries were ligated. Where large 
veins ran through infected aneu¬ 
risms, they were ligated in 2 places 
and resected. Death occurred in 8 of 
his operated cases, 4 of the fatal 
cases being, aneurisms of the sub¬ 
clavian. Bier (Beitr. z. klin. Chir., 
xcvi, 556, 1915). 

In 13 cases of gunshot aneurisms 
treated by suturing the injured ves¬ 
sels, recovery was prompt and com¬ 
plete in all, and there have been no 
complications since. This result was 
also obtained in 25 of 29 cases in 
which the vessel was ligated, in 2 
amputation was required later, and 2 
others died from hemorrhage from 
an erosion. The circulation pro¬ 
ceeds in all the cured cases with 
nothing to suggest that the men are 
not quite normal. von Haberer 
(Wiener klin. Woch., May 6, 1915). 

In traumatic aneurism the best op¬ 
eration is considered by the writer 
to be quadruple ligation. It may be 
applied even in cases where there is 
perforation of the carotid at the bi¬ 
furcation, when quintuple ligatures 
are applied; none of the cases so op¬ 
erated upon has been lost. Quenu 
(Bull, et mem. Soc. de chir. de Paris, 
xli, 592, 1915). 

To lessen the dangers of gangrene 
after operation for aneurism, the 
writer resorts to the following 
method; The limb is made anemic 
by inhibiting the entire circulation 
below the aneurism for 2 minutes by 
means of a constrictor, then releasing 
the constriction and compressing the 
artery above the aneurism. If an 
active hyperemic reaction is obtained 
the collateral circulation is sufficient. 
L. Moszkowicz (Beit. z. klin. Chir., 
xcvii, 569, 1915). 

Conditions related to aneurisms in¬ 
clude certain nevi, cavernous angi¬ 
oma, aneurism by anastomosis, and 
arterial angioma or cirsoid aneu¬ 
rism. These conditions suggest new 
growths or tumors more than aneu¬ 


risms. Some are congenital; others 
are acquired, and the aneurism by 
anastomosis, a vascular tumor con¬ 
sisting of involved arteries, veins, and 
capillaries, which may reach an enor¬ 
mous size, is present. The arterial 
angioma or cirsoid aneurism usually 
occurs upon the head about the time 
of adolescence. It may be congen¬ 
ital or follow traumatism. The ar¬ 
teries are enormously dilated and 
very tortuous; the bruit may be so 
loud as to interfere with the patient’s 
sleep. These conditions are usually 
treated by electrolysis, ligation, or 
excision. 

\V. Wayne Babcock, 

Philadelphia. 

ANGINA LUDOVICI. See 

Pharynx and Tonsils, Diseases of. 

ANGINA PECTORIS.— DEFI¬ 
NITION. —Angina pectoris (steno¬ 
cardia, breast-pang) is the name 
given to a group of symptoms which 
usually depends upon organic disease 
of the heart or aorta. An attack 
consists in the sudden onset of agon¬ 
izing pain in the precordial or sternal 
regions, accompanied by a feeling 
of constriction and in severe cases by 
a sense of impending death. The pain 
radiates into the back, the shoulders, 
and the arms, particularly the left. 
The patient is pale, haggard, motion¬ 
less, and often bathed with cold per¬ 
spiration. 

SYMPTOMS. —Suddenly, after ex¬ 
ertion, excitement, or a hearty meal, 
the patient feels an excruciating, 
burning, or tearing pain in the heart 
or beneath the sternum, accompanied 
with a sense of constriction {angere, 
to throttle), as if the heart were in a 
vise. The pain radiates into .the 
back, upward into the shoulders, and 


671 


ANGINA PECTORIS (VICKERY). 


down the left arm, often even to the 
fingertips. It may be felt in both 
arms, in the neck and head, and even 
in the trunk and lower extremities. 
“In true angina the seat of the pain 
may be entirely away from the chest, 
and may be, as in Lord Clarendon’s 
father, at the inner aspect of the arm, 
or about the wrist, or in rare in¬ 
stances confined to the side of the 
neck, or even to one testis” (Osier). 
After an attack, there may be tender¬ 
ness above and outside the left nipple 
and in the left arm. 

The pain is explained by James 
Mackenzie as a sensory reflex due to 
irritation of the 1st, 2d, and 3d dorsal 
and 8th cervical nerves, and the sense 
of constriction to reflex stimulation 
of the intercostal nerves. 

Paroxysms occur in which pain is 
slight or absent (angina sine dolore). 
Early attacks are often of this sort. 
Later on there may still be no pain, or 
the paroxysms ^ may sometimes be 
painful and at other times not. 

A feeling of numbness accompanies 
the pain. There is a sense of impend¬ 
ing dissolution. The sufferer sits or 
stands immobile and hardly dares to 
breathe. Yet there is no real dyspnea. 
The face is pale or livid; the forehead 
wet with perspiration. The pulse 
may remain strong and regular. 
Usually it is accelerated and of in¬ 
creased tension. A pulse of habitual 
high tension may be somewhat 
lowered during the attack (Macken¬ 
zie). The pulse may intermit or 
vary. Exceptionally it is slowed. 
The paroxysm lasts a few seconds or 
minutes,—sometimes half an hour or 
even several hours. At the end of it 
the patient often belches gas or 
vomits or has a movement of the 
bowels, with great relief. The in¬ 


ference that indigestion has caused 
the paroxysm is natural, but probably 
erroneous; although it is true that 
even slight exertion directly after a 
meal may precipitate an attack. 

The less found wrong with the 
heart upon examination, the more 
certain may one be of the diagnosis. 
In a series of SdO cardiovascular and 
cardiorenal cases there were 35 cases 
of genuine angina pectoris. One- 
third had succumbed to an acute an¬ 
ginal attack, and two-thirds to grad¬ 
ual cardiac death. J. E. Talley (Med. 
Rec., Nov. 6, 1915). 

The cases may be divided into two 
groups: the angina of effort and the 
angina of decubitus, but in the later 
stages of either form of the disease 
the distinction becomes less clearly 
marked, and either form may rapidly 
be followed by the other. In deter¬ 
mining what organic lesions may be 
present, very great importance is at¬ 
tached to the results of radioscopic 
examination. As a rule, in the angina 
of effort, aortitis is present. The 
qualitative changes shown by radios¬ 
copy are diminution of transparency 
of the walls of the aorta, which on 
the screen look either uniformly dark 
or sown with scattered dark patches. 
Very often there is more or less com¬ 
plete immobility of the vascular con¬ 
tours, indicating loss of elasticity in 
the vessel walls. Radioscopy may 
also reveal modifications in volume 
whose detection has escaped ordinary 
methods of observation. One change 
of much significance in the diagnosis 
of the epigastralgic form of the dis¬ 
ease is enlargement of the aortic 
arch. H. Vaquez (Arch, des mal. du 
coeur, Mar.-Apr., 1915). 

The attack may prove immediately 
fatal. If not, the patient is left ex¬ 
hausted, but regains his usual condi¬ 
tion in a few hours or days. 

The attack is almost sure to be re¬ 
peated. This may happen in an hour 
or not for weeks or months. The 
length of the interval depends greatly 


672 


ANGINA PECTORIS (VICKERY). 


upon the persistence of the patient in 
avoiding the exciting causes. After 
a severe attack, rest in bed is desir¬ 
able for several days, or, if the patient 
is much enfeebled, for a week or two. 
Successive paroxysms occur with 
gradually increasing readiness. 

The diagnosis of angina pectoris, 
at least in its milder form, cannot be 
made from the history alone. The 
other forms of cardiac pain, of toxic 
or neurotic origin, the latter espe¬ 
cially in women, may exactly simu¬ 
late a true angina pectoris. 

In diagnosing between true and 
false, organic or functional, there is 
one physical sign which the writer 
believes positive. It is so slight, and 
apparently so insignificant, that one 
almost hesitates to mention it. It is 
simply a slight clicking sound, of a 
harsh or rough quality, accompany¬ 
ing, or following at barely percept¬ 
ible interval, the sound of aortic 
closure. It is not ^n accentuation of 
the closure sound of the valve, such 
as the loud, clean, “cork and bottle” 
aortic second sound, which is sig¬ 
nificant of high arterial tension. G. 
R. Butler (Archives of Diagnosis, 
Oct., 1909). 

The most frequent exciting cause 
of seizures is overexertion, though 
walking, eating heartily, and emo¬ 
tional outbursts have also their etio¬ 
logical place. A sense of constric¬ 
tion without pain occurring after the 
ordinarily exciting causes is always 
highly suggestive. A striking fact is 
the frequency with which patients 
remain unwarned by experience of 
the dangers of carelessness. A large 
proportion of patients with embolic 
or thrombotic obstruction of a large 
branch of a coronary artery have 
died suddenly soon after the accident, 
and yet at autopsy pathologists have 
found evidence of long-standing ob¬ 
struction. Coronary obstruction may 
cause an anginal seizure, and yet the 
patient not die at once nor even soon. 
J. B. Herrick and F. R. Nuzum 
(Trans. Amer. Med. Assoc.; N. Y. 
Med. Jour., June 16, 1917). 


While the physical pain of angina 
pectoris is the essential and initial 
manifestation of the syndrome, the 
angor, an expression of the high de¬ 
gree of emotional anxiety, is a close 
second. In certain particularly emo¬ 
tional subjects, the fright awakened 
by a slight attack of pain is so 
marked that the primary, essential 
manifestation may be overlooked by 
the examining physician. The fear of 
death in angina pectoris seems to re¬ 
sult from the combined influence of 
the physical pain and the intense sub¬ 
jective exhaustion, which leads to the 
mental conception that, as some 
patients have expressed it, all the 
processes and activities of nature 
have ceased. R. Benon (Presse med., 
Jan. 21, 1920). 

DIAGNOSIS. —In true angina pec¬ 
toris skilled observers almost invaria¬ 
bly find evidence of organic cardiac 
or aortic lesion. In a supposed case 
these should be sought most care¬ 
fully. Particularly to be looked for 
are arteriosclerosis, hypertrophy or 
dilatation of the left ventricle, aortic 
regurgitation, and feebleness of the 
muscular power of the heart with 
facial pallor, sometimes lividity, 
sweats, and coldness of the surface. 

According to Mackenzie, angina pec¬ 
toris is an evidence of an exhaustion of 
the function of contractility, the pain and 
reflex muscular contraction being reflex 
phenomena due solely to an impairment 
of the contractile function of the heart. 
This does not, however, explain the en¬ 
tire situation, for W. J. Pulley (N. Y. 
Med. Jour., Nov. 8, 1913) believes there 
must of necessity be present with it a 
great distress of the function of tonicity, 
if not a beginning impairment. The pains 
are protective, by causing the patient to 
cease muscular efforts, and tend to rest 
the heart. The fear also is protective by 
causing the patient temporarily to cease 
v/orries and excesses of all kinds. The 
flushed face, due to reflex stimulation of 
the vasodilators of the superficial capil¬ 
laries, also tends to reduce vascular super- 


ANGINA PECTORIS (VICKERY). 


673 


tension. The contraction of the intercos¬ 
tal muscles is also protective; it prevents 
deep breathing, which increases the arte¬ 
rial tension, and provides a splint to pro¬ 
tect the already stretched and weakened 
aortic walls. Editors. 

Intercostal neuralgia causes pain 
along an intercostal nerve, not radiat¬ 
ing as in angina pectoris. It presents 
points tender to pressure near the 
vertebrae and sternum and in the 
axilla. It is not associated with dis¬ 
ordered circulation. It is more com¬ 
mon in women than in men. 

Gastralgia is apt to occur when the 
stomach is empty. The pain does not 
stream into the shoulder and arm. 
While there may be collapse and a 
sense of impending death, there is no 
evidence of heart disease. Like in¬ 
tercostal neuralgia it is likely to occur 
in anemic young women, rather than 
in middle-aged men. 

On the other hand, the pain of true 
angina pectoris may be felt lower 
down than the precordia. And, as 
already stated, the termination of an 
attack may be marked by the dis¬ 
charge of gas. Particularly if there 
is no extreme cardiac pain, this may 
lead the patient, and in some instances 
has led his physician astray. 

Cardiac asthma is dyspnea due to 
a weak heart and occurring more or 
less paroxysmally. Pain is not 
prominent. The picture is apt to in¬ 
clude pulmonary edema, enlarged 
liver, and dropsy, and it could hardly 
be mistaken for angina pectoris. 
Mitral disease is not apt to be asso¬ 
ciated with angina pectoris, and relief 
from attacks is often experienced 
when a mitral leak develops in an 
aortic case. 

The recognition of cardiac lesions 
observed after attacks of angina pec¬ 
toris is of great importance, inasmuch 


as it leads the physician in charge to 
insist on perfect rest for the patient 
for days or even weeks after a severe 
attack, and thus prevents, in some in¬ 
stances, sudden death. The cases in 
which the attacks are followed by the 
appearance of clinical signs in the 
heart may be divided into three 
classes. In the first group there is a 
rise of temperature and a slight en¬ 
largement of the cardiac area of dull¬ 
ness. The fever may be slight, but 
if other causes are excluded it is of 
great value in the diagnosis of myo¬ 
carditis following angina pectoris. In 
the second group there is*, in addition 
to fever,'5a/distiiiet dilatation of one or 
other of the cardiac cavities, which can 
readily be discerned on physical exami¬ 
nation. Finally, in the third group, 
there develops an acute endocarditis 
following an attack. In spite of the fact 
that clinically the occurrence of acute 
endocarditis after angina pectoris is not 
a well-recognized phenomenon as yet, 
it has long since been described patho¬ 
logically. Kernig (Roussky Vratch, 
Oct. 30, 1904). 

“Pseudoangin a /*—Pseudoangina 
pectoris, or hysterical angina, occurs 
in females or neurasthenic men, 
usually under the age of 40, without 
evidence of organic cardiovascular 
changes. There are low tension, 
feeble second sound, and soft arteries. 
The attacks are spontaneous and are 
apt to be nocturnal and periodic 
(menstrual). They last an hour or 
two, being more prolonged than the 
true paroxysms. The patient is agi¬ 
tated, writhes, or walks about the 
room, and talks. The heart feels not 
constricted, but distended. The pain 
is not apt to be so severe as in true 
angina pectoris. Paresthesise and 
vasomotor symptoms are prominent. 
The patient’s symptoms are some¬ 
times colored by his having consulted 
encyclopedias and the like (Broad- 
bent). Death never occurs. 


l-43 


674 


ANGINA PECTORIS (VICKERY). 


Angina pectoris in its typical form is 
a rare disease. Pseudoangina, or car¬ 
diac asthenia, as it is frequently called, 
is much more common. It is erroneous 
to speak of angina pectoris as a neuro¬ 
sis of the heart, as in the great majority 
of instances there are organic changes 
in the coronary circulation, the cardiac 
muscle, or lesions of the aortic orifice. 
Neurotic angina is exceptional, is al¬ 
most always associated with spasm, or 
with a sudden increase in intracardiac 
pressure. Beverly Robinson (Amer. 
Jour. Med. Sci., Feb., 1902). 

Painless angina is much more com¬ 
mon than one would suppose it to be 
from the infrequency with which it is 
mentioned; but, in all probability, the 
disease is not always recognized, and the 
patient’s sufferings are attributed to hys¬ 
teria or some reflex disturbance. When 
the symptoms are accompanied by a di¬ 
lated right heart or distinctly athero¬ 
matous changes the diagnosis is easy, 
but when physical signs are absent it 
is difficult to arrive at an absolute opin¬ 
ion. If, when free from the paroxysms, 
the patient continually suffers from a 
feeling of weight or distress over the 
precordia, and has a tendency to take 
occasional deep inspirations, there is a 
strong probability that the right ven¬ 
tricle is affected, and this amounts to 
certainty if the symptoms are invariably 
produced or aggravated by exertion. 
This form of angina is entirely different 
from the painful variety, and in many 
instances demands a diametrically oppo¬ 
site treatment. W. W. Kerr (Jour. 
Amer. Med. Assoc., May 29, 1909). 

Hysteria.—It should, of course, be 
remembered that hysteria may be 
combined with organic disease, and 
that a careful physical examination 
should be made in any suspected 
case; but the discovery of mitral dis¬ 
ease would not be inconsi.stent with 
a diagnosis of pseudoangina. 

There is a nervous form of syphilitic 
angina which is distinct from hysterical 
angina pectoris. The two conditions 
may be distinguished as follows: In 
hysterical angina the attacks come on. 


as a rule, at night; on examination 
there are found hysterical areas on 
the skin of the chest, and the attacks 
begin with paresthesia of such an 
area, and end in tears, sobs, and other 
manifestations of excitement. The 
syphilitic attack of the nervous type 
is preceded by fatigue, not by ex¬ 
citement. It is very important to 
distingish the nervous syphilitic type 
from the organic syphilitic angina, 
which depends upon a lesion of the 
heart muscle itself. The chief char¬ 
acteristic of these is the presence of 
periodic attacks of angina with dysp¬ 
nea between the attacks. M. J. Breit- 
man (Vratch, Nov. 14, 1900). 

Hysterical angina pectoris is common, 
especially before the age of 40. It is 
most frequent in women. The crises in 
childhood are less severe than those of 
adult life. Almost anything may be 
the cause of the attack, even acute 
articular rheumatism. Frequent parox¬ 
ysms are often noted about the meno¬ 
pause. Sometimes an attack occurs by 
suggestion from seeing a paroxysm in 
another. There is precordial pain, 
often with a distinct aura. The parox¬ 
ysms occur at night, periodically. 
About the precordia is generally found 
an area of marked hyperesthesia. Pal¬ 
pitation, rapid pulse, and vasomotor 
symptoms are common. In fact the 
symptomatology is polymorphous. In 
some cases true aortitis or endocarditis 
may exist, yet the attacks of angina 
pectoris are hysterical. Mercklen 
(Medecine moderne, Apr. 23, 1902). 

Syphilis.—A history of syphilis in 
a man, even if under 40 years of age, 
renders the occurrence of true angina 
pectoris less improbable than it other¬ 
wise would be, for there is a possibility 
of syphilitic aortitis obstructing the ori¬ 
fices of the coronaries. 

Tobacco, Tea, etc.—Excess in to¬ 
bacco (less often alcohol, tea, and 
coffee) and lead poisoning may occasion 
spurious angina, or again they may 
aggravate a genuine paroxysm depend¬ 
ing on organic lesions. 


ANGINA PECTORIS (VICKERY). 


675 


While certain cases are evidently 
true angina and others ecjually ob¬ 
viously pseudoangina, some are ex¬ 
tremely puzzling. All these attacks 
(true and “false”) have this much in 
common, that for the time being the 
heart is unable to perform the work 
demanded of it; so that they differ 
more in etiology and prognosis than 
in immediate- condition. 

ETIOLOGY. —Males over 40 years 
of age in comfortable worldly cir¬ 
cumstances make up the majority of 
sufferers from angina pectoris. Pre- 
dis])osing causes are: alcohol, syph¬ 
ilis (arteriosclerosis, tabes dorsalis), 
rheumatism, gout, diabetes, chronic 
nephritis, and bacterial infection (in¬ 
fluenza, plague, malaria). Sometimes 
attacks are hereditary. 

As exciting causes may be named: 
])hysical exertion, mental strain, pro¬ 
found emotion, and digestive disturb¬ 
ances. 

The writer observed several cases 
of angina pectoris, in which hyper¬ 
acidity of the gastric secretion was 
shown by an Ewald and Boas test 
breakfast with a bland meal taken the 
previous evening, and usually a glass 
of milk before retiring. These cases 
may explain the anachronism of an 
epigastric or abdominal angina pec¬ 
toris, both an impossibility. He re¬ 
calls Latham’s view that angina pec¬ 
toris is a cramp of the heart, excited 
by the hyperacid gastric juice through 
the filaments of the vagus; a fact 
which should not appear strange to 
any one familiar with the violent 
spasms excited by hyperacid secre¬ 
tion in spasmodic closure of the py¬ 
lorus. This cardiac spasm may 
supervene in any and all the various 
forms of cardiac disease, which ex¬ 
plains the many contradictions set 
forth by Allbutt. H. Illoway (N. Y. 
Med. Jour., May 25, 1918). 

The attacks may appear in the 
daytime, especially at first; but some 


of the worst occur at night; so that 
finally the patient may dread going to 
sleep. 

A point that stands out prominently 
in the writer’s experience is the fre¬ 
quency of angina pectoris in physi¬ 
cians. Thirty-three of his patients 
were physicians, a larger number 
than all the other professions put to¬ 
gether. Only 7 were above 60 years 
of age, one a man of 80, with aortic 
valve disease. The only compara¬ 
tively young man in the list, 35, was 
seen nearly twenty years ago in an 
attack of the greatest severity. 
Worry and tobacco seem to have 
been tbe cause. He has had no at¬ 
tack now for years. Two cases were 
in the fourth decade, 13 in the fifth, 
and 11 in the sixth. Neither alcohol 
nor syphilis was a factor in any case; 
of the 26 patients under 60, 18 had 
pronounced arteriosclerosis and 5 
had valvular disease. In a group of 
20 men, every one of whom Osier 
knew personally, the outstanding 
feature was the incessant treadmill of 
practice, and yet every one of these 
men had an added factor, worry. 

So far as symptoms are concerned, 
the writer’s cases fall into three 
groups: 1, les formes frusfes; 2, mild, 

and, 3, severe. 

1. The mildest form, "'les formes 
friistes” of the French, with substernal 
tension, uneasiness, distress, rising 
gradually to positive pain, is a not in¬ 
frequent complaint, one, indeed, from 
which few escape, is associated with 
three conditions. Emotion is the 
most common and the least serious 
cause. 

2. Under the mild form, angina 
minor, come 43 cases. Osier has 
grouped under these the neurotic, 
vasomotor, and toxic forms, the vari¬ 
eties which we formerly spoke of as 
false, or pseudo-, angina. The 
special features of this variety are: 
the greater frequency in women, the 
milder character of the attacks, and 
the hopeful outlook. 

3. Severe angina, angina major, is 
represented by 225 cases, of which 


676 


ANGINA PECTORIS (VICKERY). 


211 were in men. Two special fea¬ 
tures here are, existence in a large 
proportion of all cases of organic 
change in the arteries and liability to 
sudden death. Osier (Jour. Amer. 
Med. Assoc., from Lancet, Mar. 12, 
1910). 

Angina from tobacco can be agon¬ 
izing, but it always ceases with the 
withdrawal of the narcotic; where 
the angina persists despite this with¬ 
drawal, it is necessary to make a 
Wassermann test for syphilis. Three 
cases reported in which a positive re¬ 
action indicated the proper mercurial 
treatment, which was followed by 
immediate relief after other measures 
had proved inert. C. Feissinger 
(Semaine med., Apr. 2, 1913). 

The angina pectoris following over¬ 
exertion is merely a primary dilata¬ 
tion of the left heart when the heart 
has been “forced.” Tobacco can 
only evoke an attack with hitherto 
latent organic trouble, but is not 
capable of inducing the latter. Huch- 
ard found a history of syphilis in 35 
of 150 cases of angina pectoris and 
the author in 30 of 100, and this be¬ 
fore the Wassermann reaction was 
known. H. Vaquez (Arch, des Mai 
du Coeur, Mar.-Apr., 1915). 

An analysis of 178 cases showed 
that the great majority of them oc¬ 
curred between the ages of 55 and 
64. In 26 per cent, no definite lesion 
was detected either in the heart or in 
the aorta. In 24 per cent, there was 
a valvular lesion, and in 25 per cent, 
there were aortic dilatation and aneu¬ 
rism. Bramwell (Edinburgh Med. 
Jour., Dec., 1915). 

PATHOLOGY. —It is exceptional 
for attacks of true angina pectoris to be 
observed in persons presenting no evi¬ 
dence of organic circulatory lesion. 
The commonest underlying conditions 
are sclerosis of the coronary arteries, 
degeneration of the myocardium, car¬ 
diac hypertrophy, atheroma of the 
aorta, aneurism of that vessel near its 
origin, and aortic regurgitation. There 
is, however, “hardly an affection of the 


walls or cavities of the heart, scarcely a 
morbid condition of the arteries that 
nourish it or spring from it, with which 
the distressing malady has not been 
observed to be associated” (Da Costa). 

Recent writers lay stress on oblitera¬ 
tion of the lumen of the coronary arter¬ 
ies as the essential basis of true angina 
pectoris, which obliteration may be oc¬ 
casioned either by sclerosis of the ves¬ 
sels or by changes in the aorta at their 
origin. “So intimately associated is the 
true paroxysm with sclerotic conditions 
of the coronary arteries that it is ex¬ 
tremely rare apart from them” (Osier). 
Huchard held the same view. 

The pain of angina depends upon 
vascular distention in the mediasti¬ 
num, which is the result of a more or 
less localized vasodilatation and of a 
mpre or less generalized peripheral 
vasoconstriction. It would seem that 
the angina is not due to the organic 
lesions any more than is asthma due 
to emphysema, or migraine to athe¬ 
roma of cranial vessels. The con¬ 
nection between the organic lesions 
and angina should then be ascribed 
to the chronic peripheral vasocon¬ 
striction, which constitutes the ear¬ 
liest stages of many forms of chronic 
organic disease of the heart and 
vessels. 

Preventive treatment resolves itself 
into the prevention of exaggerated 
peripheral vasoconstriction, continu¬ 
ous or recurrent. Purin-free diet, 
cutting down of the intake of carbo¬ 
hydrates, especially the saccharine 
carbohydrates, and the fats, is advo¬ 
cated. Francis Hare (Med. Rec., 
Oct. 20, 1906). 

Angina results from an alteration 
in the working of the muscle-fibers in 
any part of the cardiovascular sys¬ 
tem, whereby painful afferent stim¬ 
uli are excited. Cold, emotion, toxic 
agei+s interfering with the orderly 
action of the peripheral mechanism, 
increase the tension in the pump 
walls or in the larger central mains, 
causing strain, and a type of abnor- 


ANGINA PECTORIS (VICKERY). 


677 


mal contraction enough to excite in 
the involuntary muscles painful affer¬ 
ent stimuli. Mackenzie suggests that 
there is rapid exhaustion of the func¬ 
tion of contractibility, which is, after 
all, only the fatigue on which Allan 
Burns laid str'-ss. lii a disturbance 
of this Gaskellian function is to be 
sought the origin of the pain, whether 
in heart or arteries. In stretching, in 
disturbance of the wall tension at any 
point, and in a pain-producing resist¬ 
ance to this by the muscle elements 
lie the essence of the phenomena. 
In a man with arteriosclerosis and 
high pressure, and all the more likely 
if he has a local lesion, a syphilitic 
aortitis for example, disturbance, at 
any point, of the tension of the wall 
permits the stretching of its tissues. 
Spasm or narrowing of a coronary 
artery, or even of one branch, may 
so modify the action of a section of 
the heart that it works with disturbed 
tension, and there are stretching and 
strain sufficient to arouse painful 
sensations. Or the heart may be in 
the same state as the leg muscles of 
a man with intermittent claudication, 
working smoothly when quiet, but in¬ 
stantly an effort is made, or a wave 
of emotion touches the peripheral 
vessels, anything which heightens the 
pressure and disturbs the normal 
contraction brings on a crisis of pain. 
Osier (Lancet, Mar. 26, 1910). 

The writers observed a man of 34, 
who developed attacks of angina pec¬ 
toris and died in 5 months. There 
was no trace of venereal disease or 
alcoholism, but signs of tobacco pois¬ 
oning had been so pronounced that 
his daily ration of cigars and cigar¬ 
ettes was reduced. The case would 
have been cited as one of fatal 
tobacco poisoning but necropsy re¬ 
vealed syphilitic lesions in the aorta 
partly closing up the openings into 
the coronary arteries. Mouriquand 
and. Bouchut (Arch, des Mal. du 
Coeur, Oct., 1912). 

The writer does not deny all sig¬ 
nificance to the prevailing doctrine 
of coronary sclerosis, but its meaning 
has hitherto been virtually negative. 


The hypothesis of Mackenzie is un¬ 
tenable. Angina pectoris does not 
mean a want of muscular strength, of 
contractility, but the result of “brus¬ 
que hypertension in the left ventricle, 
both systolic and diastolic from the 
increased tone, together with an un¬ 
regulated and disordered excitability” 
of the “primitive fascia and of the 
cardiac nerves.” Castelli (Riv. crit. 
di din. med., Dec. 6, 1913). 

Heberden—who introduced the 
name of angina pectoris for the affec¬ 
tion—declared in 1768 that its most 
common termination is sudden death. 
This holds good today, yet we are 
unable to state the rationale. In 
1889 McWilliam advanced the belief 
that in many cases of sudden death a 
myocardial fibrillation could be in¬ 
voked as the efficient cause; but only 
recently have animal experiments 
given some corroboration to this 
view. Sudden death in angina pec¬ 
toris is considered by the writer to 
be the result of ventricular fibrilla¬ 
tion, but the direct actual proof can 
be supplied only by electrocardi¬ 
ography. The patient does not die 
from paralysis of the heart but from 
the direct opposite, the excessive 
production of impulses. We already 
have data.which shows that angina 
pectoris occurs only when there is 
temporary ischemia of the heart, and 
we know by experiments on animals 
that this ischemia is liable to pre¬ 
cipitate fibrillation of the ventricles, 
and also that the ischemia predis¬ 
poses the heart to fibrillation. Her- 
ing (Miinch. med. Woch., Nov. 2, 
1915). 

The immediate, precipitating condi¬ 
tions of a paroxysm are not known, but 
they are supposed to be connected with 
disturbances of the vagus, or, perhaps, 
the sympathetic nerves. Nothnagel re¬ 
ported a series of cases under the title 
“angina pectoris vasomotoria” which 
seemed to be due to a pure neurosis. 
They followed exposure to cold, and 
were ushered in by spasm of the pe¬ 
ripheral arterioles, which presumably 


678 


ANGINA PECTORIS (VICKERY). 


produced the cardiac disturbance be¬ 
cause of the increased exertion de¬ 
manded of the heart in order to propel 
the blood through narrowed channels. 

Broadbent describes angina vaso¬ 
motoria as a comparatively favorable 
class of cases of high arterial tension 
associated with general arteriosclerosis 
and a hypertrophied heart capable of 
powerful contraction. “The circulation 
in the coronary arteries may be suffi¬ 
cient for ordinary needs, but when the 
arterial tension is further raised by 
exertion or increase of peripheral re¬ 
sistance attacks of angina are induced.” 

From a neuralgia or a neurosis true 
angina pectoris differs in being fre¬ 
quently fatal, in attacking men ten 
times as often as women, and in being 
associated with organic changes in 
the neighboring structures, viz.: the 
heart and aorta. 

Lesions of the cardiac plexus and the 
branches of the vagus have been found 
in repeated instances of angina pectoris, 
but that such lesions are invariably pres¬ 
ent and essential to the disorder has not 
yet been proved. “The cardiac nerves 
may be seriously implicated in aneur¬ 
ism, in mediastinal tumors, in adherent 
pericardium, and in the exudate of 
acute pericarditis, without causing the 
slightest pain” (Osier). 

The late Sir Benjamin W. Richard¬ 
son regarded angina pectoris as an 
actual disease analogous (as Trousseau 
held) to epilepsy, and due to a disturb¬ 
ance in the sympathetic nervous system. 

Attention called to the coincidence 
of disturbances in circulation else¬ 
where. In a man of 33, angina pec¬ 
toris, Raynaud’s disease, loss of 1 
eye from disturbance in the circula¬ 
tion in the retina, and intermittent 
claudication occurred in turn. The 
first symptoms were an attack of 
angina pectoris after a bombardment. 


These conditions were all on the left 
side, a fact which points to a nervous 
origin for them all, and seems to ex¬ 
clude local endarteritis. The attack 
in the fingers was brought on by 
cold, the attack in the toe by walk¬ 
ing, the angina pectoris by fatigue 
and emotions. The fatal outcome in 
this case shows that even attacks 
with a nervous origin may prove fa¬ 
tal and that spasm of the artery cap¬ 
able of producing total anemia in a 
finger can well arrest the heart. Bard 
(Presse med., Jan. 26, 1921). 

Debove says that in tabetic angina 
pectoris there is no organic lesion of the 
heart or large vessels, and that the at¬ 
tack must be regarded as a visceral 
crisis. Dana refers cardiac crises in 
tabes to a degenerative irritation of the 
vagus. It should, however, be remem¬ 
bered that aortic disease is rather fre¬ 
quent in tabetic patients. 

In regard to the causation of attacks 
of angina pectoris in the graver cases 
which are associated with serious struc¬ 
tural disease of the heart and vessels, J. 
Burney Yeo states that in by far the 
greater number of deaths from organic 
disease of the heart all the various 
lesions may be present which have been 
found in fatal cases of angina and yet 
no true anginal attacks have ever been 
complained of. In his opinion there is 
some additional circumstance needed 
to account for the angina. The most 
serious forms of angina seem to have 
a complex causation. First, there must 
be a neurosal element; the nerves of 
the cardiac plexus suffer irritation, and 
an intense cardiac nerve-pain is excited; 
this acts as a shock to the motor nerves 
of the heart, and thus reacts on the 
heart-muscle, which, in fatal cases, is 
already on the verge of failure from 
organic causes; and, if there should be 
excited at the same time some reflex 
arterial spasm, the heart will have to 


ANGINA PECTORIS (VICKERY). 


679 


encounter an increased peripheral re¬ 
sistance as well. In such cases the 
rapidity of the fatal issue is no argu¬ 
ment against the neuralgic nature of 
the angina. In certain conditions, espe¬ 
cially in habitual high arterial tension, 
strain is apt to fall (when the aortic 
valves are competent) rather on the 
first part of the aorta than on the ven¬ 
tricular surface, and anginal attacks 
are more prone to occur in these cases, 
as this part of the aorta is in such close 
relation with the nerves of the cardiac 
plexus, rather than in those cases in 
which the strain is felt on the interior 
of the cardiac cavities. 

The causation of the less grave and 
more remediable forms of angina is 
also, in many instances, complex. A 
cardiovascular system feeble and poorly 
nourished on account of anemia may 
be submitted to undue strain; or 
there may be some intoxication—such 
as that of tea, tobacco, alcohol, gout, 
or some intestinal toxin—irritating the 
cardiac and vasomotor nerves, increas¬ 
ing peripheral resistance, and so ex¬ 
citing anginal attacks, which may alto¬ 
gether pass away and be completely 
recovered from. Vasomotor spasm as 
a unique cause of attacks of angina 
must be set aside as inconsistent with 
extended clinical experience. 

Cases of angina pectoris, both of the 
milder and graver forms, occur without 
any evidence of vasomotor spasm or of 
heightened arterial tension; and the 
conditions of heightened arterial ten¬ 
sion, together with a feeble cardiac mus¬ 
cle, very commonly coexist, without 
any tendency whatever to the develop¬ 
ment of anginal attacks. The argument 
in favor of a vasomotor causation has 
been inferred from therapeutic experi¬ 
ment and the relief to the paroxysm 
which has attended the use of agents 


which cause arterial relaxation. But 
most, if not all, of these vasodilators 
are also anesthetics, and, as Balfour has 
pointed out, it is probably to their 
anodyne action on the sensory cardiac 
nerves that they owe their chief effi¬ 
cacy ; Grainger Stewart also has pointed 
out that nitrite of amyl has a direct 
effect on nervous structures, and that 
it relieves other forms of neuralgia. 

Certain fallacious conceptions of 
angina pectoris prevail. Thus, in 
true cardiovascular angina pectoris, 
peripheral arterial sclerosis, cardiac 
hypertrophy, and high blood-pressure 
are essential. This is by no means 
always the fact. Arterial change may 
be widespread and the coronaries 
sclerotic without hypertrophy of the 
heart or rise in blood-pressure. The 
sclerotic or atheromatous process may 
be quite limited, localized to the begin¬ 
ning of the aorta, and only encroaching 
a little on the coronaries, while the pe¬ 
ripheral vessels may be normal. Espe¬ 
cially in syphilitic cases are the condi¬ 
tions liable to be thus localized. In some 
of the most serious cases there may be 
no abnormal arterial pressure, indicat¬ 
ing, perhaps, a weakened cardiac muscle. 
The finding of aneurism or lesion of the 
aortic valves does not exclude angina, 
but is rather in its favor. The attacks 
are not always few in number, and fol¬ 
lowing exertion, and life is not neces¬ 
sarily cut off within a few months after 
the appearance of the disease. Patients 
may live a number of years with com¬ 
paratively frequent attacks. While com¬ 
paratively rare in women, the disease is 
by no means unknown, and serious mis¬ 
takes may be made in diagnosis, espe¬ 
cially in nervous and hysterical cases. 
The cardiopath is often a neuropath 
also. Pain is not always excessive. It 
may be mild or even lacking; its radia¬ 
tion is variable. Even in fatal cases 
there may be no constant pain. Uncon¬ 
sciousness, though unusual, is seen at 
times, and, while the patient usually is 
afraid to move, and will not lie down, 
there are exceptions to this rule. Eruc¬ 
tations or vomiting during an attack do 


680 


ANGINA PECTORIS (VICKERY). 


not prove it to be a false angina and 
not organic or cardiovascular. While 
the disease is very grave, there is no 
certainty that death is imminent. 
The kidneys, as well as the heart, 
must be investigated as regards prog¬ 
nosis. J. B. Herrick (Jour. Amer. 
Med. Assoc., Oct. 22, 1910). 

PROGNOSIS.—The underlying 
condition is apt to prove fatal event¬ 
ually, and it may end life in the first 
paroxysm; but a careful regimen may 
prolong existence for years, and Flint, 
Bendel, and Labolbary have each re¬ 
ported cases of recovery. 

The signs of danger during any par¬ 
ticular attack are the subjective sense 
of impending death and the feebleness 
and irregularity of the pulse. The gen¬ 
eral prognosis is, of course, influenced 
by the stage which the organic circula¬ 
tory changes have already reached. 

The pseudoattacks are apt to be 
repeated oftener than are the genuine, 
but the prognosis is good, both as to 
life and as to the final disappearance of 
the trouble. 

In common with all other observ¬ 
ers, the writer finds that angina pec¬ 
toris is more common in the male 
than in the female, in the ratio of 
63 to 48. The youngest patient in his 
series of cases was 29 years old; the 
oldest, 76. The longest duration of 
the recurring syndrome was seven¬ 
teen years; the shortest was found in 
three who died in the first attack. 

In the cases of angina in which 
coronary sclerosis alone existed we 
find 3 dead in the first attack and 7 
others dead. Of the latter, 2 died of 
diabetic complications, 1 of compli¬ 
cating pneumonia in the status an- 
ginosus, death being due to acute car¬ 
diac dilatation, 1 of a cerebral and 
another of a gastric hemorrhage. So 
that, in all, in only 6 cases could 
death be attributed to the coronary 
sclerosis. The duration of the dis- 
- ease in these cases varied from six¬ 
teen months to seventeen years, and 


all were males. In the 29 cases of 
coronary sclerosis there is but 1 fe¬ 
male. 

When the obstruction is due to 
thrombosis or embolism, the attack 
is usually fatal, either immediately or, 
later on, as the result of changes in 
the myocardium. The attack is al¬ 
ways immediately fatal when one 
coronary artery is closed. As a rule, 
death occurs instantaneously where 
the descending or circumflex branches 
are completely closed, but occasionally 
the patient survives for a few days, 
as is shown by myocardial infarcts 
found post mortem. Forchheimer’s ex¬ 
perience leads him to believe that 
when both cardiac asthma and an¬ 
gina pectoris are present from the 
onset the outlook for improvement is 
very small. But he does not agree 
with Neubiirger, who states that in 
coronary sclerosis there are 3 stages 
of myocardial changes, which de¬ 
velop and which are always fatal. 

So far as the duration of the dis¬ 
ease is concerned, aside from those 
who died in the first attack, in 8 the 
disease lasted from one to two years; 
in 4 from two to four years, and in 1 
for seventeen years. Of those alive, 

4 have had the disease from eight to 
ten years, the same number from five 
to eight years, and 10 from four to 
five years. F. Forchheimer (Jour. 
Amer. Med. Assoc., from Ill. Med. 
Jour., May, 1910). 

TREATMENT.—During a parox¬ 
ysm the first remedies to employ are 
such as will dilate the arterioles. Ni¬ 
trite of amyl is the best because it 
acts with the greatest rapidity. A 
pearl” of this drug may be crushed 
in a handkerchief or in cotton placed 
in the bottom of a glass tumbler, and 
inhaled. Nitroglycerin may be in¬ 
jected subcutaneously to 

grain), or a tablet of this substance 
may be masticated, or a minim of 
spiritus glycerylis nitratis may be 
placed upon the tongue. It is readily 
absorbed from the mouth and acts 


ANGINA PECTORIS (VICKERY). 


681 


almost as quickly as when given 
hypodermically. Erythrol tetranitrate 
has an action like nitroglycerin, but 
milder and decidedly more prolonged. 
It may be given in tablets of ^ to 2 
grains. 

The nitrites are sometimes marvel¬ 
ously efficacious in checking an at¬ 
tack, and their failure to give benefit 
does not exclude true angina. In 
some cases digitalis does more good 
than all the nitrites or iodides, and in 
this the writer’s experience agrees 
with that of Romberg, who advised it 
in some cases. J. B. Herrick (Jour. 
Amer. Med. Assoc., Oct. 22, 1910). 

The writer h <? long been convinced 
that the absorption of toxic products 
during metabolism is an etiologic 
factor of importance in the patho¬ 
genesis of all functional troubles of 
the heart and of the aorta. In 123 
anginal patients, 80 of whom have 
been followed for a sufficient time to 
warrant therapeutic conclusions, diet¬ 
etic treatment intended to avoid 
toxemia was used. The first day, the 
patient having angina pectoris at¬ 
tacks is given nothing but water. On 
the second day milk is given in quan¬ 
tities varying from 114 to 3 quarts. 
Nothing but milk is allowed for from 
1 to 3 weeks, according to the 
severity of the case and the response 
to treatment. In the milder cases, at 
the end of a week, soups made of 
milk and various kinds of cereals 
are added and continued for 1 or 2 
weeks. At the end of this time 
cooked vegetables without salt are 
added and continued for a month or 
two. Then eggs and a small amount 
of meat are allowed. Milk still re¬ 
mains the basis of the diet, and no 
salt is added to the food. Soca 
(Arch. d. mal. du Coeur, Aug., 1915). 

The theory that the real seat of 
the disease is usually in the arterial 
walls and often in the external coat 
accounts for the incidence of the pain 
much better than the older view that 
the disease resulted from an affec¬ 
tion of the coronary arteries with 
degeneration of the myocardium. 


The prognosis is more hopeful than 
is generally believed, under proper 
care and treatment, a very important 
part of which is abundant rest with 
heart tonics as needed. In the treat¬ 
ment, nitrates are among the most 
valuable remedies, but they are usu- 
ally given in insufficient doses. The 
sublingual administration of fresh 
hypodermic tablets of nitroglycerin 
is of great value in relieving pain. It 
is of the utmost importance that 
these tablets should be fresh and that 
they should be given in sufficiently 
large doses. Given sublingually, the 
full effect of these tablets is experi¬ 
enced in from 1 to 3 minutes, where¬ 
as taken into the stomach the effi¬ 
ciency is reduced by half and the 
effect delayed for about 10 minutes. 
When an attack comes on 2 or more 
tablets of Koo grain (0.00065 Gm.) of 
nitroglycerin should be taken at 
once and repeated every few minutes 
until the desired effect is obtained. 
The effect of amyl nitrite is not 
as certain as nitroglycerin. Sodium 
nitrite seems to possess some toxic 
property and is liable to disturb the 
stomach. Erythrol tetranitrate was 
found to cause more headache and 
did not relieve the pain as promptly 
as nitroglycerin, although its effects 
may be of longer duration. The 
heart may be protected against in¬ 
hibition shock by the use of atropine 
in doses as much as %oo grain (0.002 
Gm.) may be needed for some adults. 
E. Fletcher Ingals (Jour. Amer. Med. 
Assoc., Apr. 6, 1918). 

Relief by these means is often im¬ 
mediate ; but, if not, ether should be 
inhaled. Chloroform is also advised 
by excellent authorities. Flint thinks 
it not without danger, if the heart is 
weak; ether, on the other hand, is 
a stimulant. Morphine, subcutane¬ 
ously, is a valuable and sometimes 
an indispensable remedy. Whittaker 
advises that it be given with cau¬ 
tion in a condition which may any¬ 
way terminate in sudden death. The 


682 


ANGINA PECTORIS (VICKERY). 


morphine grain) may be guarded 
by atropine (^q grain), and in case 
of alarm also by strychnine (%(> to 
%o grain). Electricity has also been 
recommended. 

Factors capable of bringing on the 
pain should be carefully avoided; 
every renewal of it keeps up the sum 
of stimuli. If for this end absolute 
stillness in bed be required, then bed 
it must be, with the corresponding 
reduction of food. If at first the at¬ 
tacks are not abolished, they will be 
mitigated, and will gradually taper off. 
All measures, medicinal, dietetic, etc., 
known to reduce arterial pressures 
should be enforced. Sir Lauder 
Brunton’s potent means, the nitrites, 
are indispensable. To guard against 
vagus inhibition, atropine must be 
administered regularly. In very pain¬ 
ful cases morphine may be needed 
also. An ice-bag applied cautiously 
and intermittently to the upper tho¬ 
racic spine may prove helpful. The 
cause then requires treatment. Of 
new remedies two have seemed in the 
author’s experience to be efficacious, 
more especially in angina minor— 
namely, (a) the high-frequency cur¬ 
rent, and (b) the administration of 
the lactic acid bacUlus by the method 
of Metchnikoff. Baths and massage 
cannot be prescribed in any urgent 
stage of the disease. Causes of ec¬ 
centric irritation must be discovered 
and neutralized. The patient must be 
warned never to swallow quickly, 
nor to bolt large morsels. Diuretin 
and aspirin have their advocates. 
Chloroform is very dangerous in an¬ 
gina. In syncopic failure of the 
heart artificial respiration should be 
tried. Allbutt (Brit. Med. Jour., Oct. 
16, 1909). 

Although the writer applied the 
Wassermann test in many cases of 
true angina pectoris, he obtained a 
positive response in only 33 per cent. 
Yet, after treatment as for syphilis 
there were no further attacks in 90 
per cent, of the cases. In some there 
was a slight return of the pains later, 
but they subsided anew oil resump¬ 


tion of treatment. Arsphenamin 
should not be used, as it brings on 
serious disturbances with aortic les¬ 
ions. He obtained the best results 
with mercurial treatment in minute 
doses, on alternate days, in a series 
of 15 cases. Josue (Paris Med., July 
5, 1919). 

Hot and stimulating applications 
over the precordia, such as a strong 
mustard poultice, are appropriate, as 
are also heat and friction for the ex¬ 
tremities. Sometimes an ice-bag is 
put over the heart. By some it is 
preferred to heat. Alcohol and aro¬ 
matic spirits of ammonia are of bene¬ 
fit in case the cardiac action is feeble. 
Syncope demands such drugs as digi¬ 
talin, caffeine, strychnine, and cam¬ 
phor, employed hypodermically. 

Good results obtained from theo¬ 
bromine in angina pectoris. In 1 
case a man of 46 had been suffering 
for 2 months from repeated attacks 
of angina pectoris, recurring so con¬ 
stantly that he did not dare to go to 
bed; the attacks only lasted a few 
minutes, but had already induced 
great debility and distress. Exam¬ 
ination revealed insufficiency of the 
aortic valve. He was given 0.5 Gm. 
(7.5 grains) of theobromine, and the 
dose was repeated at bedtime. There 
were no further attacks then or later. 
The treatment with theobromine must 
be long kept up, for months and 
years. Marchiafava (Policlinico, Feb. 
28, 1909). 

Prolonged rest in bed advocated in 
true organic cases. Marked improve¬ 
ment noted in most of the 20 cases 
studied. The patient should remain in 
bed at least 2 weeks, prolonged to 6 
or 8 weeks in cases that cannot walk 
without bringing on anginal pain. 
Milk diet to be imposed from the 
start; later farinaceous foods added. 
Drug medication by theobromine, 
nitroglycerin, and even morphine and 
digitalin also utilized. Greatest im¬ 
provement in old patients and those 
losing weight during treatment; least. 


ANGINA PECTORIS (VICKERY). 


683 ' 


in cases with associated aortic insuf¬ 
ficiency. Fiessinger (Bull, de I’Acad. 
de med., Nov. 29, 1910). 

The present writer has known oxy¬ 
gen to contribute to a favorable result 
in collapse due to chronic myocarditis 
with dilatation of the left ventricle, 
and it might be well for a subject of 
angina pectoris to keep some ready 
in his house. 

The painful attacks incident to car¬ 
diac disease, such as angina pectoris, 
also paroxysms of tachycardia, can 
be mitigated by causing the patient 
to belch up wind from the stomach, 
owing to the fact that the heart and 
the stomach are both innervated by 
the pneumogastric nerve. Eructation 
is produced by the following pro¬ 
cedure: The patient, seated, takes a 
small drink of water and holds it in 
his mouth. He then throws his head, 
as far backward as possible and swal¬ 
lows the water. The posture is such 
as to stretch the esophagus and in¬ 
duce in the pharynx a sensation 
which causes eructation, provided the 
result is not voluntarily prevented by 
the patient. It is well to warn the 
person that an eructation is desired; 
otherwise, he may restrain it out of 
a sense of decency. Max Herz 
(Semaine medicale, June 3, 1908). 

Dyspeptic disturbances are respon¬ 
sible for or at least aggravate angina 
pectoris in many cases. Great benefit 
can be derived from magnesium 
oxide and peroxide to neutralize ab¬ 
normal production of gases and the 
gastric juice, and promote bowel 
functioning. Chlapowski (Med. Klinik, 
June 5, 1910). 

Between attacks it is of vital impor¬ 
tance to avoid the predisposing and 
exciting causes. Rest and moderation 
are demanded, especially after meals. 
As for drugs, nitroglycerin, taken af¬ 
ter meals in doses just short of caus¬ 
ing headache, has a distinct inhibitory 
efifect upon the paroxysms. In some 
instances it might be better to order 
it every three hours, as its influence 


is not long continued. Nitrite of 
sodium (2 to 5 grains) may replace 
nitroglycerin. 

Laxatives and eliminative treat¬ 
ment by alkalies are often of great 
value. 

Surgical treatment of angina pec¬ 
toris is advocated by Jonnesco, 

The phenomena of angina pectoris 
are caused by irritation of the cardio- 
aortic plexus due to a constant lesion 
of the aorta. By breaking the cen¬ 
tripetal route between the cardio- 
aortic apparatus and the nerve cen¬ 
ters by resecting the cervical sympa¬ 
thetic nerve, the advent of the aortic 
reflexes in the nerve centers and the 
reaction of these centers can be pre¬ 
vented. The writer performed a 
resection of the left cervical sympa¬ 
thetic in a case ol angina pectoris. 
A definite cure resulted. Because of 
the brilliant result from the unilateral 
operation, he believes that a resec¬ 
tion on the left side will usually be 
sufficient, but as the operation is 
simple and harmless, it is preferable 
to perform it on both sides. T. Jon¬ 
nesco (Presse med., xxix, 193, 1921). 

The persistent use of potassic io¬ 
dide is very effective. Ten or fifteen 
grains may be given thrice daily 
before meals in half a glassful of 
water; or twenty grains three times 
a day for twenty days, followed by 
nitroglycerin for ten days. The io¬ 
dide is believed to dilate the arterioles 
and to promote arterial nutrition. See 
supposed that also by enlarging the 
caliber of the coronary arteries it in¬ 
vigorated the myocardium. 

Arsenic and phosphorus in small 
doses also tend to avert the parox¬ 
ysms. In case of fatty degeneration 
of the heart they would be contra¬ 
indicated. Barium chloride in doses 
of Yio to % grain after meals is a 
good tonic for cardiac inefficiency, 
and often relieves cardiac pain. 


684 


ANGINA PECTORIS (VICKERY). 


Quinine and methylene blue have 
also been recommended. 

The treatment by saline baths and 
by the Schott method of exercises 
has a most potent effect in improving 
the condition of the cardiac muscle 
and vessels, and appears to have a 
direct effect in making the attacks 
less numerous and severe, and even 
in causing them to cease during a 
period of months or years. The 
movements must be made with es¬ 
pecial care and caution in these cases, 
and the resistance at the onset must 
be at a minimum. The artificial 
saline baths should contain from 1 to 
3 per cent, of salt, and from ^ 

per cent, of chloride of calcium, and 
should gradually be strengthened by 
the addition of carbonic acid. 

Massage three times a week and 
persisted in for months may be of 
great benefit. 

In most cases it is best to prohibit 
alcohol. 

The cardiac tonics— sparteine, stro- 
phanthus, strychnine, valerian, and in 
suitable cases digitalis —are of the 
greatest utility. 

The general tendency to anemia 
and defective oxygenation must never 
be lost sight of, and general tonics, 
including the use of oxygen gas, will 
be of excellent service. 

Attacks of pseudoangina may be 
treated with asafetida, ammoniated 
tincture of valerian, or coriipound 
spirit of ether, and the outward em¬ 
ployment of heat, friction, and rube¬ 
facients. Sometimes recourse must 
be had, however reluctantly, to mor¬ 
phine. The statement in clear and 
decided language of a favorable prog¬ 
nosis is of great benefit. Between at¬ 
tacks the underlying condition should 
be carefully sought and treated. 


The frequent and indiscriminate 
use of such terms as false angina pec¬ 
toris, angina sine dolore, angina 
vasomotor, etc,, gives no clear sense 
of their etiology or pathology. The 
treatment should be based on these 
as follows;— 

Hypertensive Cardiovascular Disease 
with Myocardial Insufficiency. —In this 
group the usual cardiac changes are 
ventricular hypertrophy, usually left, 
but sometimes right also; a patchy 
fibrous myocarditis; thickened aortal 
and mitral cusps; lime deposits on 
the first portion of the aorta and 
atheroma and thickening of both 
coronaries. There is a systolic blood- 
pressure of about 190 mm.; rough 
systolic first and sharply accentuated 
second sound at the right base; 
heaving apical impulse; urine with 
or without albumin or casts; varying 
grades of edema and visceral conges¬ 
tion; dyspnea usually upon excretion. 
The pains are commonly dull, most 
marked in the precordium and 
radiate to the neck and arms. As to 
the cause of the pain, it seems to be 
.due to nutritional cardiac disturb¬ 
ance from inadequate coronary cir¬ 
culation. The author depends mainly 
on digitalis, preferably the tincture, 
given in l5-minim (1 c.c.) doses 3 
times a day, continued even when 
pain and other symptoms disappear, 
for an indefinite period. Mental ex¬ 
citement and stress should be avoided. 
For the edema, theobromin sodium 
salicylate in 1-gram (15-grain) doses 
t. i. d., on alternate days in water or 
in wafers are recommended. The 
Carrel diet was an excellent aid. In 
cases in which a luetic condition is 
proved or suspected the iodides are 
useful, otherwise they proved of no 
value in the relief of the pain. 

Hypertension and Myocardial In¬ 
sufficiency with Unstable Vasomotor 
Mechanism. —This is a smaller group 
with the highest systolic blood-pres- ' 
sure, around 180, and marked diurnal 
variations, precordial pains following 
exercise. Emphysema and myocar¬ 
ditis are the main pathological en¬ 
tities. Experimental subcutaneous 


ANHALONIUM LEWINIl. 


685 


injections of nitroglycerin in doses 
of Yao grain (0.0013 Gm.) t. i. d., has 
a marked temporary effect upon the 
blood-pressure and usually upon the 
symptomr. This or other vasodila¬ 
tors given at the onset of pain are 
likely to give great relief. Digitalis 
was not as beneficial as in Group 1. 

Uremic Group. —This group is char¬ 
acterized by headache, nausea, vomit¬ 
ing, varying grades of anemia, parox¬ 
ysmal, dyspnea, precordial distress, 
high systolic and diastolic pressure, 
nocturnal polyuria, and changes in 
the retina. The precordial pains are 
not relieved by nitroglycerin, digi¬ 
talis, or diuretin. The pains are ap¬ 
parently caused by retained excre- 
mentitious products in the circula¬ 
tion. Dietetic measures, especially 
low protein and high carbohydrates, 
are of most value. 

Acute Rheumatic Endocarditis and 
Rheumatic Endocarditic Exacerbations. 
—These cases usually occur in young 
persons with mild tachycardia, no 
dyspnea or decompensation, and with 
marked auscultatory evidence of val¬ 
vular disease, usually mitral stenosis. 
There were “sticking” pains in the 
heart itself, and usually, no Head’s 
zones. The rapid heart action and 
the precordial pain seem due to fresh 
exacerbations of endocarditis. The 
best medication is sodium salicylate 
in 1-Gm. (15-grain) doses hourly 
until 6 doses have been taken or tin¬ 
nitus occurs. Bromides in moderate 
doses are helpful; absolute rest is 
necessary. 

General Circulatory Failure and De¬ 
compensation from Endomyocardial 
Disease. —The cause of the precordial 
pain is apparently the nutritional 
disturbance in the heart, due to cir¬ 
culatory failure. Head’s zones are 
often present. The treatment indi¬ 
cated for the first group is also indi¬ 
cated here. 

Embolic Infarcts in the Main Coron¬ 
aries and Their Branches.—\n several 
cases with intermittent pains lasting 
days or weeks, the symptoms were 
possibly caused by embolic infarcts 
of the coronaries of the second or 


third order. There was a rise of 
temperature, acute endocarditis, pro¬ 
gressive tendency of the disease, and 
tender local precordial areas. 

Cardiac Lues. —This is a very fre¬ 
quent cause of precordial pain. The 
latter is usually substernal, dull, 
boring, and aching. It may, how¬ 
ever, have the distribution of the 
types already described. Head’s 
zon3s -are rare. The main patho¬ 
logical changes occur in the aorta 
and myocardium. Salvarsan com¬ 
bined with the usual mixed treatment 
is of great value. 

Premature Arteriosclerosis. — This 
rare group found in young adults, is 
characterized by persistent precor¬ 
dial distress, lasting often for months. 
Gastric symptoms similar to those 
of hyperacidity may predominate. 
Physical examination affords no hint 
of the severity of the pathological 
process. The cause for the sclerosis 
is still undetermined, but it may be 
the result of some infection and 
toxemia. Except digitalis for tem¬ 
porary relief, treatment is of no 
avail. 

Tabacism. —The pains may be dull 
and aching, or sharp and radiating. 
The first premonition may be very 
sharp lancinating precordial pains 
radiating to the left shoulder and 
forearm and accompanied by uncon¬ 
sciousness. Most tobacco pains and 
arrhythmias cease when smoking is 
stopped. Occasionally they recur. 
Nitroglycerin given regularly or with 
the onset of pains is sometimes of 
benefit. S. Neuhof (Med. Rec., Jan. 
15, 1916). 

Herman F. Vickery, 

Boston. 

ANGIOMATA. See Blood-ves¬ 
sels, Tumors of. 

ANGIONEUROTIC EDEMA. 

See Ascites and Edema. 

ANHALONIUM LEWINIl 

(Mescal Button).—The mescal button is 
obtained from a plant growing in the val¬ 
ley of the Rio Grande, in Mexico. The 


686 


ANHALONILIM LEWINII. 


plant is of the family CactacejE. The tops 
of the plant when dried constitute the 
commercial Anhalonium Lewinii, first in¬ 
troduced by Lewin. The buttons or seeds 
are brownish in color, shaped like a top, 
and from 1 to 1^2 inches in diameter. 
They are hard and can be pulverized in 
the mortar only with difficulty. In the 
mouth, however, under the action of the 
saliva, they swell and rapidly become soft, 
imparting a bitter, nauseous taste and 
causing a marked sensation of tingling 
in the fauces. Four alkaloids,—mescaline, 
anhalonine, anhalonidine, and lophopho- 
rine,—closely similar in their physiological 
effects, have been extracted from this 
species of anhalonium. From the related 
plant Anhalonium Williamsi the alkaloid 
pellotine is derived. 

PREPARATIONS AND DOSE.—The 

following preparations may be used: 
Tincture (10 per cent.); dose, 1 to 2 drams 
(4.0 to 8.0 C.C.). Fluidextract (1(X) per 
cent.); dose, 7^2 to 15 minims (0.5 to 1.0 
C.C.). Powder; dose, 7^ to 15 grains (0.5 
to 1.0 Gm.). The tincture and fluidextract 
should be made according to the processes 
prescribed in the United States Pharma¬ 
copoeia for such preparations. 

PHYSIOLOGICAL ACTION.— Lewin 
found anhalonium to be an intensely 
poisonous drug. A few drops of the de¬ 
coction used by him in the frog sufficed to 
produce almost instantly changes consist¬ 
ing chiefly in the appearance of shrinking 
of the body, so that the batrachian seemed 
to pass into a mummified condition. 
Simultaneously, the animal raised itself 
upon its extremities and remained stand¬ 
ing in this position like an ordinary quad¬ 
ruped, or crawled about. After fifteen 
minutes this spastic condition passed off 
and the frog rapidly returned to the nor¬ 
mal state. When larger amounts were 
given death occurred in tetanic rigidity. 
The symptoms produced seemed closely 
allied to those of strychnine, Lewin noting 
that even after the spinal cord was sev¬ 
ered peripheral irritation induced tetanus. 
In pigeons it was found that the drug pro¬ 
duced convulsive vomiting in a few mo¬ 
ments when injected hypodermically. The 
bird spread its wings, crouched down to 
the ground, and when disturbed exhibited 
muscular twitchings. Later the head was 


drawn sharply back, the mouth opened 
widely, and general convulsions appeared. 
When death occurred the heart was al¬ 
ways found in diastole. In rabbits the 
symptoms resembled those of strychnine 
poisoning. 

In the human subject anhalonium in 
large doses produces an effect in some 
ways closely resembling that of Indian 
hemp: visions ranging from flashes of 
color to beautiful landscapes and figures, 
illusions of time and space, etc. This and 
related plants are employed as intoxicants 
by certain Mexican Indians in connection 
with religious ceremonies. According to 
Prentiss and Morgan, color effects consti¬ 
tute the main feature of the drug’s action 
on the brain. Consciousness remains un¬ 
impaired throughout its effects. Mitchell 
states that sometimes symptoms resem¬ 
bling the visual phenomena of ophthalmic 
migraine are experienced. The after¬ 
effects were also found by him to be 
markedly unpleasant, nausea and headache 
appearing which lasted for several hours. 
Heffter in 1898 carried out investigations 
cn himself with the object of determining 
which of the active ingredients of mescal 
produced the visual hallucinations. An 
alcoholic extract of the buttons equivalent 
to 4^2 drams was taken, and afterward a 
corresponding amount of each of the alka¬ 
loids. The symptoms produced both by 
the alcoholic extract and by mescaline 
( 1^2 grains) were colored visual hallu¬ 
cinations, slowing of the pulse, pupillary 
dilatations, loss of time relations, heavi¬ 
ness of the limbs, nausea, and headache. 
Anhalonine and anhalonidine in like 
amounts induced sleepiness without visual 
phenomena, while lophophorine (%o grain) 
caused occipital headache, facial redness 
and burning, and a temporary slowing of 
the pulse. Mescaline was thus shown to 
be the active constituent of anhalonium in 
respect of the visual phenomena. 

According to Dixon, who carried out 
careful pharmacologic studies of anhalo¬ 
nium in frogs, cats, and rabbits and wit¬ 
nessed its effects in man, the chief effects 
of the drug in therapeutic doses appear 
to be: (1) Direct stimulation of the in¬ 
tracardiac ganglia; (2) initial slowing of 
the heart; (3) elevation of arterial tension; 
(4) direct stimulation of the brain centers 


ANIMAL EXTRACTS (SAJOUS). 


687 


iind of the motor spinal centers, as shown 
by an increase in reflex excitability. 

Full doses of anhalonium induce motor 
weakness and inco-ordination. In still 
larger doses difficulty of respiration ap¬ 
pears. Lethal doses, Dixon found, pro¬ 
duce complete paralysis, and death is 
caused by respiratory failure. 

THERAPEUTIC USES.— Prentiss and 
Morgan employed anhalonium in various 
conditions dependent upon excessive nerv¬ 
ous iritability, with considerable success. 
While not a hypnotic in itself, the drug in 
therapeutic doses (7 to 15 grains) often 
removed the cause of the insomnia, and 
thus conduced to natural sleep. It has 
been credited with beneficial effects, espe¬ 
cially in neuralgic headache, acute de¬ 
lirium, mania, melancholia and hypochon¬ 
driasis, hysteria, irritative cough, and 
colic. Anhalonium tincture in drop doses 
has been claimed to be useful as a sus- 
tainer of the heart action. But little 
knowledge of its clinical value in circu¬ 
latory disorders has as yet, however, been 
obtained. According to Landry, the drug 
is a useful adjuvant to digitalis. 

The taste of the liquid preparations of 
anhalonium is bitter and unpleasant, but 
can readily be disguised. Lewin recom¬ 
mended for this purpose the use of fluid- 
extract of licorice and elixir of yerba 
Santa (fluidextractum eriodictyi). The 
powdered drug may be administered in 
capsules or cachets. 

The chief untoward action to be feared 
in the event of excessive dosage of this 
drug is respiratory depression. S. 

ANHIDROSIS, or ANIDROSIS. 

See Sweat Glands, Diseases of. 

ANIMAL EXTRACTS, OR 

ORGANOTHERAPY.— Owing 
mainly to the fact that physiologists 
even at the present writing (1921) 
have failed to discover the functions 
of any ductless gland, despite consid¬ 
erable effort to do so, empiricism 
still prevails to a very large extent. 
Textbooks of therapeutics and prac¬ 
tice still adhere to the convenient 
statements that an organic prepara¬ 


tion “is useful,” that “it is recom¬ 
mended,” or “has proven valuable” 
in this or that disease; that is to say, 
without attempting to define its mode 
of action. The cause of this is not 
difficult to find: So many assump¬ 
tions as to the actual functions of the 
organs used therapeutically have been 
vouchsafed on totally inadequate ex¬ 
perimental evidence that textbook 
authors adopt none. 

The writer of the present article 
has taken another course. Rejecting 
all assumptions based on inadequate 
data, he has done his own experimen¬ 
tal work and used data from all 
branches of medicine, clinical and 
auxiliary, as a foundation for his own 
deductions. Time has sanctioned 
this course. The conclusions he pub¬ 
lished in the earlier editions of his 
“Internal Secretions,” and elsewhere, 
have steadily gained adherents, sup¬ 
ported as they have been by an in¬ 
creasing number of confirmatory facts 
contributed independently by experi¬ 
menters and clinicians. He feels it 
his duty, therefore, to adopt his own 
views as the foundation of the sum¬ 
mary of organotherapy submitted, 
knowing that they will best subserve 
the interests of the practitioner. 

The human body is managed by 
the endocrine glands of the body. 
Every individual from the time he is 
born until the time he dies is under 
the influence of these many different 
kinds of elements—some of them 
having to do with the development of 
the bones and teeth, some with the 
development of the body and nerv¬ 
ous system, some with the develop¬ 
ment of the mind, etc., and, later on— 
with the introduction of sex fea¬ 
tures—with reproduction. Still later 
on, these elements have to do with 
the preservation of these structures 
and functions which constitute the 


688 


ANIMAL EXTRACTS (SAJOUS). 


body and mind, and if these glands 
become under- or over- active there 
is a disturbance of the specific func¬ 
tions which these component parts 
are supposed to perform; and since 
these glands are dependent on each 
other, the upset of one disturbs the 
rhythmical action of the others. 

In recent years our knowledge as 
to the physiology of the ductless 
glands has been put to the test by 
endocrine therapy, and there is no 
longer any doubt that the future of 
medicine lies along these lines. In 
the writer’s practice, endocrine ther¬ 
apy has displayed and replaced the 
old time drugs, so that practically 90 
per cent, of all prescriptions for in¬ 
ternal use consist almost entirely, if 
not wholly, of endocrine extracts. 
The varying forms of amenorrhea, 
most of the menorrhagias and met¬ 
rorrhagias, threatened miscarriage, 
habitual miscarriage, sterility, the dis¬ 
orders and disturbances of the cli¬ 
macterium, and many other states 
met with in gynecological practice 
may be corrected in many instances 
specifically by a certain extract; in 
many other cases, by a combination 
of extracts. S. W. Handler (Med. 
Record, Mar. 15, 1919). 

Instead of using the extracts of or¬ 
gans the venous blood issuing from 
the organ should be used. This con¬ 
tains the true internal secretion 
while the cells of the organ cease 
secreting this product when they are 
dead. Hence the removal of the 
organ from the body to make the ex¬ 
tract not only arrests production of 
the internal secretion but probably 
modifies essentially the delicate se¬ 
cretion already on hand in the tissues 
of the organ. Instead of a living se¬ 
cretion only a dead and possibly de¬ 
composed product is obtained. The 
efferent blood contains the secretion 
in its maximum vital potency. In 
1911 the writer published researches 
on the thyroid secretion thus ob¬ 
tained in the efferent blood, and in 
1913 and 1915 similar researches on 
the venous blood from the supra- 
renals, pancreas, and testicles. Man- 


fredi announced in 1913 that the ef¬ 
ferent blood from the pancreas in¬ 
hibited certain actions of epinephrin. 
He cites further researches since by 
Ollini, Masera, Durand and 8 others. 
The difficulty in obtaining the effer¬ 
ent blood or. lymph hampers and 
limits the research in this line, but 
this should be the goal toward which 
we strive. G. Ghedini (Jour. Amer. 
Med. Assoc., from Gaz. degli Osped. 
e delle Clin., Jan. 5, 1919). 

Clinical, anatomic, histologic and 
bacteriologic observations led the 
writer to conclude as follows: The 
absence of certain accessory food fac¬ 
tors from the dietary—improperly 
termed “antineuritic”—leads not only 
to functional and degenerative changes 
in the central nervous system, but to 
similar changes in every organ and 
tissue of the body. The morbid 
state to which their absence gives 
rise is not a neuritis. The symptom 
complex resulting from the absence 
of these substances is due (a) to a 
chronic inanition; (b) to derangement 
of function of the organs of digestion 
and assimilation; (c) to disordered 
endocrine function; (d) to malnutri¬ 
tion of the nervous system, and (e) 
to hypersuprarenalinemia. Certain 
organs undergo hypertrophy; others 
atrophy. Edema has invariably (100 
per cent.) been associated with great 
hypertrophy of the suprarenal glands, 
while 85 per cent, of all patients hav¬ 
ing great amount of epinephrin in 
such patients as determined by phys¬ 
iologic methods, has been consider¬ 
ably in excess of that found in nor¬ 
mal suprarenals. Inanition gives rise 
to a similar state of suprarenal hy¬ 
pertrophy, and to a similar state of 
atrophy of other organs, the brain 
excepted. The edema of inanition 
and of beriberi is believed to be in¬ 
itiated by the increased intracapillary 
pressure which results from the in¬ 
creased production of epinephrin, act¬ 
ing in association with malnutrition 
of the tissues. R. McCarrison (Brit. 
Med. Jour., Feb. 15, 1919). 

Since the internal secretions and 
their hormones have been definitely 


ANIMAL EXTRACTS (SAJOUS). 


689 


connected with the general protective 
mechanism of the body, they form 
the systemic immunizing mechanism 
of the organism. In reaching this 
conclusion so pregnant with proba¬ 
bilities that internal medicine as a 
whole will be completely revolution¬ 
ized, Sajous, for more than a score 
of years, has by his conscientious 
labors, analysis of all reliable data 
derived from all sources—medical 
and auxiliary—and from coordinated 
syntheses of all factors entering into 
the problems, reached conclusions 
which have filled many obscure la- 
cumcy and bid fair to make a logical 
whole of what now, in medicine, is 
decidedly chaotic. While these hor¬ 
mones are the active defensive agents 
and their efficiency controlled by 
pharmaco-endocrinology, yet it may 
be that these same hormones may so 
increase the proteolytic activity of 
the digestive enzymes (defensive fer¬ 
ments) as to cause them not only to 
destroy pathogenic agents, bacteria* 
toxins, and certain other poisons, but 
also the blood cells (hemolysis) and 
even the tissues themselves (autol¬ 
ysis). 

The recognition of this long con¬ 
tinued and constructive work has 
been recognized by the establishment 
of a chair of endocrinology at the 
University of Pennsylvania, where 
he, as professor, with additional fa¬ 
cilities, may continue to add to the 
resources of scientific medicine. 
Reynold Webb Wilcox (The Medical 
Times, Jan., 1922). 

THYROID GLAND ORGANO¬ 
THERAPY.— In the latter part of 
the last century. King, of London, 
showed experimentally that the colloid 
substance of the thyroid gland passed 
directly into the lymphatics. Schiff, of 
the University of Geneva, reviving 
views in 1859 previously held by many, 
found that this organ played an im¬ 
portant part in the economy, through 
some substance which it secreted, and 
that intraperitoneal transplantation of 


the healthy gland in a dog shortly after 
thyroidectomy had been performed 
prevented the cachexia strumipriva 
and violent nervous phenomena which 
follow this operation. Then followed, 
in 1882, the labors of the brothers Re- 
verdin, succeeded, in turn, one year 
later by those of Kocher, of Berne, 
demonstrating that, in man as well as 
in animals, the same phenomena oc¬ 
curred under identical circumstances. 

The principal postoperative symp¬ 
toms noted were: marked weakness 
and fatigue; a sensation of cold, 
pallor, hardness, and dryness; ede¬ 
matous swelling, thickening of the 
skin, and loss of hair, all with, as 
nervous phenomena: muscular stiff¬ 
ness and pains; tetany, sometimes 
attaining the violence of true tetanus, 
and even clonic convulsions. The 
brothers Reverdin termed this condi- 
dition postoperative myxedema while 
Kocher called it cachexia strumipriva. 

The thyroid gland per se was subse¬ 
quently found to be responsible only 
for the myxedematous symptoms, 
however. The two external parathy¬ 
roids, discovered in 1880 by a Swed¬ 
ish physician, Sandstrom, and the 
two internal parathyroids, discovered 
by a French physician, Nicolas, of 
Nancy, in 1893, and independently by 
Kohn, of Prague, in 1895, were sub¬ 
sequently shown through the labors 
of Gley, Vassale and Generali, Mous- 
sous, Jeandelize, and others to be re¬ 
sponsible for the nervous phenomena, 
tetany, etc. Briefly, removal of the 
thyroid alone arrested development 
and caused myxedema (cretinism in 
the young), while removal of the 
parathyroids alone was followed by 
tetany and early postoperative death. 

The observation of Schiff, con- 


690 


ANIMAL EXTRACTS (SAJOUS). 


firmed by other investigators, that 
grafting prevented the morbid effects 
of thyroidectomy as long as the grafts 
lived, led Murray and Ord to try the 
use of thyroid extract in myxedema. 
Not only was it found to counteract 
this disease by these clinicians and 
many others since, but thyroid gland, 
which includes parathyroid; but the 
latter alone, as will be shown under a 
special heading, also proved valuable 
therapeutically in other disorders. 

How are these favorable phenom¬ 
ena brought about? 

PHYSIOLOGICAL ACTION.— 

In a recently published work on general 
therapeutics, one of the contributors 
states that: “the manner in which the 
thyroid gland presides over the nutri¬ 
tion of the body is unknown. It is 
generally admitted that it furnishes an 
internal secretion, that this secretion 
is formed by the living cells of the 
vesicles, and that it is poured into the 
colloid material they contain. But our 
knowledge,’’ remarks the author, “has 
not advanced much beyond this point.” 
Thi.s naturally suggests a correspond¬ 
ing lack of knowledge concerning the 
physiological action of thyroid prepa¬ 
rations and their use as remedies. But 
here, as elsewhere in the realm of 
science, the world has not stood still. 

In truth, the last three decades have 
brought out facts which account not 
only for the nutritional phenomena 
witnessed under the influence of thy¬ 
roid preparations, however adminis¬ 
tered, but also for autoprotective or 
immunizing functions of the first order. 

ACTION ON METABOLISM.— 
Some physiologists hold that the thy¬ 
roid and parathyroids, by means of an 
internal secretion, “exercise an im¬ 
portant control over the processes of 


nutrition of the body,” as Howell 
states; others contend that the purpose 
of these organs “is to neutralize or de¬ 
stroy toxic substances formed in the 
metabolism of the rest of the body.” 
Others again assert that it increases 
metabolic activity, especially catabo¬ 
lism. The one great factor which stays 
all progress in this connection is the 
persistent identification of these func¬ 
tions as separate entities, whereas they 
are in reality the manifestations of a 
single function. That such is the case 
is easily demonstrable: No one can 
deny that “the processes of nutrition 
of the body” represent a phase (that of 
anabolism) of the process of metabo¬ 
lism, nor can any one deny that catab¬ 
olism, the other phase of metabolism, 
serves to “neutralize or destroy toxic 
substances” formed in the body at 
large—and to break down fats, as is 
well known. If, therefore, the thy¬ 
roid secretion serves to activate me¬ 
taholism, as first shown by two Italian 
scientists, Vassale and Generali, all the 
other processes mentioned are also in¬ 
fluenced by the thyroid. That such is 
the case has now been conclusively 
shown. 

[Chantemesse and Marie, Ballet and 
Enriques (cited by Popoff, Arch gen. de 
med., Oct., 1899), Bourneville (Arch, de 
neurol.. Sept., 1896), and Shattuck (Bos¬ 
ton Med. and Surg. Jour., June 30, 1904), 
Lorand (Lancet, Nov. 9, 1907), and many 
other clinicians, including myself, have 
noted that thyroid preparations caused a 
rise of temperature of several degrees and 
that it took part in the febrile process. 
These observations were controlled by 
those of Stiive and Thiele and Nehring 
(Zeit. f. klin. Med., xxx, p. 41, 1896), that 
thyroid extract increases over 20 per cent, 
the oxygen intake and to nearly as great 
a degree the carbonic acid output. This 
is evidently produced by the active agent 
of the thyroid secretion, iodine, for this 
halogen itself increases oxidation as well. 


ANIMAL EXTRACTS (SAJOUS). 


691 


Thus, Rabuteau, Milanese, and Bouchard 
{C.-r. de la Soc. de Biol, pp. 227, 237, 
1873), Henrijean, and Corin (Arch, de 
pharmacodyn., ii, 1896) have all noted an 
increase of nitrogen excretion. Wood 
(“Therapeutics,” 13th ed., p. 499, 1906) 
and Cushny (“Pharmacology and Thera¬ 
peutics; 4th ed., p. 514, 1906) state, in fact, 
that iodine can produce fever. 

Removal of the thyroid, on the other 
hand, lowers oxidation. Albertoni and 
Tizzoni and Magnus Levy (Zeit. f. klin. 
Med., xxxiii, p. 269, 1897) found, for ex¬ 
ample, that this procedure decreased 
markedly the output of carbon dioxide, 
and that it caused hypothermia. The fall 
of temperature is gradual, according to 
Lorrain-Smith (Jour, of Physiol., xvi, p. 
378, 1894), and most marked, according to 
Rouxeau (Arch, de physiol., xxix, p. 136, 
1897), at the end of the operation. The 
proportion of red corpuscles is reduced, 
according to Moussu (C. r. de la Soc. de 
biol., p. 772, 1903). Reverdin observed in 
man that the hemoglobin was also dimin¬ 
ished, while Horsley noted increased sen¬ 
sitiveness to cold. Albertoni and Tizzoni 
and Masoin found that the blood con¬ 
tained less oxygen than normally. 

This applies as well to removal of the 
parathyroids, which was found by Jean- 
delize (‘Tnsufficance thyroidenne et para- 
thyroidienne,” p. 45, 1903) also to lower 
the temperature. That the thyroid ap¬ 
paratus can itself raise the temperature, is 
shown by the febrile process and sense of 
heat with flushing observed in the sthenic 
stage of exophthalmic goiter and when 
the thyroid apparatus is overactive when 
thyroid extract is given to such cases, 
the exchanges may be increased to a sur¬ 
prising degree—77 per cent, in a case ob¬ 
served by Hirschlafif (Zeit. f. klin. Med., 
xxxvi, No. 3-4, S. 200, 1898-99). The last 
two decades have only served to confirm 
these observations. C. E. de M. S.] 

As urged by myself in 1903, the thy¬ 
roid enhances general oxidation and 
metabolism is partly due to excita¬ 
tion of the adrenals by the thyroid 
secretion contained in the blood. Star¬ 
ling has since (1906) termed “hor¬ 
mones” substances which thus act as 


stimuli to other organs, while Kraus 
and E'riedenthal, Caro, Hoskins, and 
others have found (1908-1910) that 
thyroid extracts excited the adrenals. 
In addition to this, 1 attributed (1907) 
to the thyroparathyroid principle a di¬ 
rect action on the phosphorus of all 
tissue-cells (and particularly of their 
nuclei), the iodine found by Baumann 
to be the active agent, in organic com¬ 
bination, of the thyroid secretion (as 
well as of the parathyroids, as shown 
by Gley), rendering tbe phosphorus 
more susceptible to oxidation by the 
hemoglobin. 

(Telford Smith (Lancet, Oct. 7, 1897) 
and other clinicians have observed that 
the use of thyroid preparations in 
young cretins was sometimes attended by 
softening of the bones and bending of the 
legs, notwithstanding marked general im¬ 
provement. When it is recalled that five- 
sixths of the inorganic matter of bone 
consists of calcium phosphate, it becomes 
a question whether the thyroid extract 
does not interfere with the building up of 
this tissue. That such is the case is fur¬ 
ther suggested by the facts that iodine, 
the active constituent of the thyroid secre¬ 
tion, and its salts, as shown by Henrijean 
and Corin {loc. cit.). Handheld Jones (cited 
by Wood, loc. cit.), and others, cause exces¬ 
sive elimination of phosphates and phos¬ 
phoric acid, and that thyroid preparations, 
according to Roos, Scholtz, (Central, f. 
inn. Med., xvi, pp. 1641, 1069, 1895), Pou- 
chet (Bull. gen. de therap., Sept. 15, 1905), 
and others, act in the same way. “Em¬ 
phasis must be laid,” writes Chittenden 
(Trans. Congress Amer. Phys. and Surgs., 
iv, p. 93, 1897), “upon the apparent con¬ 
nection between the thyroid gland and 
phosphoric acid metabolism,” giving as 
example “the increased excretion of P 2 O 5 
after feeding thyroids to normal animals, 
and the great decrease in the case of ani¬ 
mals with the thyroids removed.” 

The untoward effects of large doses of 
thyroid preparations on the nervous sys¬ 
tem, owing to its wealth in phosphorus 
and fats as manifested by tremor, tachy¬ 
cardia, optic neuritis [Coppez (Arch. 


692 


ANIMAL EXTRACTS (SAJOUS). 


d’Ophtal., Dec., 1900)], etc., also bespeaks 
such an action; Cyon (Arch, de physiol., 
X, p. 618, 1898), in fact, found that injec¬ 
tions of iodothyrin excited the depressor 
nerve directly to such a degree that the 
vascular pressure often declined to two- 
thirds of the normal. 

A familiar action of the thyroid prepara¬ 
tions is a rapid reduction of fat in obese 
subjects when full doses are administered. 
The presence in the fat-cell of a nucleus 
rich in phosphorus whose purpose is 
promptly to promote oxidation of the fat 
when the organism requires additional 
carbohydrates explains this action. Schon- 
dorff (Arch. f. d. ges. Physiol., Ixiii, p. 423, 
1896; Ixxii, p. 395, 1897), in fact, found that 
the reserve fats could be exhausted be¬ 
fore the nitrogenous tissues were affected. 

The mode of action of the thyroid active 
principle, iodine, is suggested by the pres¬ 
ence of this halogen in all nuclei, as 
shown by Justus (Virchow’s Archiv, 
clxxvi, S. 1, 1904) and others. “If a frag¬ 
ment of phosphorus lying on a plate is 
sprinkled with iodine,” writes Wilson 
(“Inorganic Chemistry,” p. 284, 1897), 

“the substances unite, and heat enough is 
produced to kindle the phosphorus.” 
Moreover, Roos (Miiiich med. Woch., No. 
47, p. 1157, 1896) found that in a dog 
in nitrogenous equilibrium, iodothyrin 
“caused at once a marked increase in the 
output of sodium, sodium chloride, and 
phosphoric oxide” (cited by Chittenden, 
loc. cit., p. 89). 

The experimental observations of Not¬ 
hin and White and Davies, and personal 
researches having suggested that the 
action of the adrenal secretion resembles 
that of an organized ferment, I termed it 
“thyroidase.” C. E. de M. S.] 

The writers, using dogs, tried to de¬ 
termine the value of small doses of 
commercial desiccated thyroid gland, 
given by mouth, as a means of in¬ 
creasing nitrogen elimination. To 
eliminate the determination of a 
nitrogen intake, the dogs were given 
only sugar solutions, and their nitro¬ 
gen excretion, following the adminis¬ 
tration of the thyroid gland prepara¬ 
tions, was carefully studied and tab¬ 
ulated. Examination of the tables 
presented, which show the average 


nitrogen figures for 3 days preceding 
thyroid feeding and for the days of 
administration, and 2 days subsequent 
to it, indicate that a daily dose of 
0.05 to 0.1 Gm. (J4 to 1I4 grains) of 
desiccated thyroid mixture per kilo 
(2^ pounds) of body weight is suffi¬ 
cient to produce a marked effect on 
the nitrogen elimination, with a some¬ 
what greater loss in weight than in 
the control animals. Rohde and 
Stockholm (Jour, of Biol. Chem., 
Feb., 1919). 

When in the light above, we admin¬ 
ister desiccated thyroid, which com¬ 
bines the actions of the thyroid and 
parathyroids, corresponding effects are 
produced: It renders the phosphorus 
of all tissues, and all free .substances, 
such as bacteria, wastes, toxins, etc., 
containing phosphorus, more inflam¬ 
mable or sensitive to the action of the 
oxygen in the blood. As this applies 
particularly to nerves and nerve cen¬ 
ters (all of which are especially rich in 
phosphorus), the adrenal center, and, 
therefore, the adrenals themselves, are 
excited, and, the adrenal secretion be¬ 
ing the agent which takes up the oxy¬ 
gen of the air to sustain the blood-oxy¬ 
genizing power, the supply of oxygen is 
also increased. All the various phos¬ 
phorus-laden substances are thus not 
only rendered more readily oxidizable 
by thyroid extract, but this remedy also 
provides indirectly the required oxy¬ 
gen. Hence also the familiar in¬ 
fluence of thyroid preparations on 
obesity, their action being mainly ex¬ 
ercised upon the nucleus rich in phos¬ 
phorus which fat-cells contain. 

The wonderful effects of thyroid ex¬ 
tract in cretinism can also be readily 
accounted for: The rise of tempera¬ 
ture is due to the increased oxidation 
brought about by the thyroid and 
adrenal oxidizing substances acting 
jointly; the enhanced metabolism is a 


ANIMAL EXTRACTS (SAJOUS). 


693 


normal result of the augmentation of 
general oxidization, while the increased 
appetite is due to the resulting greater 
demand for foodstuffs. The marked 
improvement in general nutrition and 
strength is a self-evident result of the 
assimilation of a greater proportion of 
food materials, and the rapid growth 
likewise. The cerebrospinal system is 
particularly influenced owing to its 
wealth in phosphorus; hence, the devel¬ 
opment of intelligence. All organs be¬ 
ing the seat of active metabolic activity 
and nutrition, the intestinal, renal, car¬ 
diac, and cutaneous and hepatic func¬ 
tions are all enhanced. Even the hair 
grows, not only in cretinism, but when 
its loss.is due to general adynamia. 

A slightly alkaline saline solution, 
or alcohol, extracts from the thyroid 
some non-coagulable material which 
is a vigorous stimulant for the gas¬ 
tric secretion. This material pro¬ 
duces its elfects at least in part by 
intensification of the functions per¬ 
formed by the terminal filaments of 
the (gastric) vagus. Extracts simi¬ 
larly made from the pathologic tis¬ 
sue of the adenomatous or hyper¬ 
trophied human glands are inert. 
Rogers, Rahe and Ablahadian (Amer. 
Jour. Physiol., Feb. 1, 1919). 

This, it must be emphasized, is the 
aggregate of effects obtained with small 
doses, at most, 1 grain of the desiccated 
thyroid (which represents 5 grains of 
the gland proper), three times a day. 
When larger doses are given another 
order of phenomena is awakened: those 
of excessive burning up, as it were, of 
the tissues. The inflammability of all 
phosphorus-laden elements being mark¬ 
edly enhanced while the quantity of 
oxidizing substance is as greatly in¬ 
creased, the tissue elements are broken 
down more rapidly than they are built 
up, beginning with the fats, and the 
patient becomes emaciated. 


THYROXIN.— Until recently the iodo- 
thyrin of Roos was deemed the probable 
active agent of the thyroid secretion, but 
the recent more precise biochemical re¬ 
searches of Edward C. Kendall, of Roch¬ 
ester, Minn., (Endocrinology, April, 1917, 
and April-June, 1918), have identified it 
as a crystalline compound containing 
iodine. The colloid of the thyroid was 
not found, as generally believed, to influ¬ 
ence the functions of the body at large. 
The crystalline compound referred to, 
“thyroxin,” was found, even in small doses, 
to supplant thyroid activity, relieving 
myxedema and cretinism and in excess 
will produce symptoms of exophthalmic 
goiter. As little as 10 milligrams 
grain) will, in fact, increase the metabolic 
rate 30 per cent. The name “thyroxin” is 
an abbreviation of “thyro-oxy-indol,” the 
CO-NH group of which is thought to pro¬ 
duce physiologic effects with iodine prob¬ 
ably as an activator. 

The exact chemical reactions involved, 
however, are still siih judice but it is theo¬ 
retically attributed to an interaction be¬ 
tween thyroxin and an amino-acid, the 
function of the thyroid from this view¬ 
point being to furnish the animal organ¬ 
ism with ammonia resulting from the de¬ 
aminization of amino-acids, leading per¬ 
haps to the formation of urea. 

Antitoxic Function.—Another func¬ 
tion definitely credited to the thyroid 
gland is “to neutralize or destroy toxic 
substances formed in the metabolism” 
(Howell). Now tetany, as shown by 
the brothers Reverdin, we have seen 
follows thyroidectomy; it is now rec¬ 
ognized that this is due to a general 
toxemia. As these phenomena were 
arrested by administering thyroid ex¬ 
tract, or by grafting, as long as the 
physiological action of these remedial 
agents lasted, it became evident that 
the thyroid supplied the blood with 
some substance which in some way de¬ 
stroyed the spasmogenic poison, i.e., 
that the thyroid product was an anti¬ 
toxic substance. This is further cur¬ 
tained by the facts: 1, that the blood 


694 


ANIMAL EXTRACTS (SAJOUS). 


of thyroidectomized animals proved 
more toxic than that of normal ani¬ 
mals, and that it caused convulsions; 
2, that the urine of thyroidectomized 
animals was also more toxic than that 
of normal animals; 3, that the trans¬ 
fusion of blood of the latter into thyroi¬ 
dectomized animals counteracted for a 
time the toxicity of both their blood and 
urine. These and other facts had 
shown that the thyroid gland—mainly 
owing to the parathyroid secretion it 
contains—is endowed with antitoxic, 
or, as they have been sometimes termed, 
“detoxicatory,” functions. 

Yes; it is evidently not only ‘‘toxic 
substances formed in the metabolism 
of the body” that the thyroparathyroid 
secretion proves antitoxic. Charrin, 
Lindemann, and others have found, for 
example, that animals succumbed more 
readily to infections after their thyroid 
had been removed; Roger and Gamier, 
Kashiwamura, and others found that 
histologically the thyroid showed evi¬ 
dences of marked activity, while Torri 
noted that this was accompanied by an 
increased production of their colloid 
substance. Hunt has shown that thy¬ 
roid feeding renders white mice much 
less susceptible to poisoning by aceto¬ 
nitrile; Vincent, Frugoni and Grixoni, 
Leopold-Levi and Rothschild, and oth¬ 
ers have observed that thyroid prep¬ 
arations combated effectively various 
infectious diseases, including erysipelas 
and septicemia. The thyroparathy¬ 
roid thus showed itself antagonistic to 
bacterial toxins and certain other poi¬ 
sons, as well as to toxic waste products. 

This action is accounted for by the 
fact, pointed out by myself in 1903 
(“Internal Secretions,” vol. i), that the 
thyroid secretion is one of the impor¬ 
tant agents in general immunity —none 
of the active factors or antibodies of 


which had been traced to their source. 
I found, however, that this action was 
indirect, i.e., that the thyroid secretion 
or extracts, while a constituent of the 
blood’s antitoxin, or alexin, increased 
the immunizing power of the latter by 
enhancing the functional activity of the 
adrenals. This stimulating influence 
on the adrenals has since been sus¬ 
tained by the investigations of Hoskins 
and others experimentally, while the 
participation of the thyroid in the im¬ 
munizing process was, four years later, 
confirmed by the researches of L. Fas- 
sin, of the Bacteriological Institute of 
Liege. 

Experiments to ascertain the influence 
of the thyroid gland on immunity. The 
first series of experiments in a large 
number of animals (dogs and rabbits) 
showed that the subcutaneous injection 
of thyroid product (fluidextract of the 
fresh gland, the thyroidin of Bur¬ 
roughs, Wellcome & Co.) is rapidly fol¬ 
lowed by an increase of alexin in the 
serum, a substance discovered by Buch¬ 
ner, generally considered as playing an 
important role in the defense of the 
body. This increase becomes evident 
as early as ten minutes after the injec¬ 
tion; it becomes accentuated after one 
hour, reaches its maximum in twenty- 
four hours; then the proportion of 
alexin in the blood recedes more or 
less rapidly until the normal is reached. 
The effects of one injection rarely last 
less than twenty-four hours or more 
than two or three days. The writer 
also found that the oral administration 
of thyroid brought about corresponding 
effects. 

To control these results as to their 
direct relationship with the thyroid, the 
writer performed complete thyroidec¬ 
tomy in 9 animals. One alone, however, 
survived the operation more than fifteen 
days, tetany occurring in all, thus show¬ 
ing that the parathyroids had been com¬ 
pletely removed. In all the operated 
animals there occurred a marked dimi¬ 
nution of the hemolytic and bactericidal 
alexin, though it never d sappeared 


ANIMAL EXTRACTS (SAJOUS). 


695 


altogether. As the diminution of alex¬ 
in might possibly have been due to 
traumatism, the operative procedures 
were repeated in fresh animals, leaving 
the thyroid in situ. Rut neither the 
• traumatism nor even removal of the 

spleen caused a reduction of alexin. 
Louise Fassin (C.-r. de la Soc. de Biol, 
vol. Ixii, pp. 388, 467, 647, 1907). 

Further researches on the nature of 
the process through which the thyroid 
secretion enhanced the autoprotective 
power of the blood and of the phago¬ 
cytic activity of the migrating and sta¬ 
tionary (endothelial) cells brought me 
in 1907 to the conclusion that the thy¬ 
roid and parathyroid secretions, acting 
jointly, served to sensitize all phos¬ 
phorus-laden cells, normal and patho¬ 
logical, and that this thyroparathyroid 
secretion and Wright’s opsonin were 
“one and the same substance.” Among 
the more direct facts which sustained 
this opinion were that, while substances 
capable, as are the opsonins, of sensi¬ 
tizing or enhancing the phagocytic ac¬ 
tivity of leucocytes had been found in 
the blood-plasma by Denys and Leclef, 
Bordet, and others, and Nolf had 
shown that they were secreted by the 
red corpuscles, my own observations 
brought out (1) that the. composition 
of these sensitizing substances was 
similar to that of the thyroparathyroid 
secretion, i.e., that they contained io¬ 
dine, nucleoproteid, and globulin, and 
(2) that opsonins, which had been as¬ 
similated to Bordet’s sensitizing sub¬ 
stance by Savtchenko and others, were 
destroyed at the same temperature as 
the thyroparathyroid .secretion, i.e., at 
60° to 65° C. Briefly, besides being 
endowed with other attributes in com¬ 
mon, the sensitizing substances of 
Denys, Bordet, etc.; Wright’s opsonins, 
and the thyroparathyroid secretion all 
proved to be plasmatic products of the 


red corpuscles, and to show similar 
chemical properties. Hence my con¬ 
clusion that it was as opsonin that 
the thyroparathyroid secretion pro¬ 
duced its main effects, and the rec¬ 
ommendation that thyroparathyroid 
preparations be used in various in¬ 
fections, acute and chronic,to enhance 
the opsonic power of the blood. My 
position has been sustained by several 
investigators. 

The writer reported the results of 
experimental and clinical observations 
which had led him to conclude that the 
opsonins of the tissue juices and ex¬ 
udates were, to a considerable extent, 
the product of the thyroid gland while 
simultaneously taking part in the main¬ 
tenance of health through its influence 
on metabolism. He noted elevation of 
the opsonic index of the serum after 
injections of thyroid extract into rab¬ 
bits. A rabbit treated with 1.5 c.c. of 
the extract at two days’ interval gave 
three days after the injection an opsonic 
index = 2, 4, for example. Another, 
given the preceding day 1 c.c. of the 
extract, gave an index of = 3.0. These 
results, obtained in many animals, and 
other experiments led the writer also 
to ascribe the opsonizing action of thy¬ 
roid extract to the thyroglobulin of 
Oswald, which is normally present in 
the thyroid gland. StepanofT (C.-r. de 
la Soc, de Biol, vol Ixvi, p. 296, 1909). 

The writer, having also advanced the 
opinion that the glands with internal 
secretion probably play an important 
role in the phenomena, of immunity, 
undertook to verify this view experi¬ 
mentally, as bad Stepanoff, at the 
Pasteur Institute. The first series of 
experiments aimed to ascertain the 
influence of hyperthyroidization on op¬ 
sonic variations in the blood of guinea- 
pigs and rabbits, using mainly the 
bacilli of tuberculosis, diphtheria, the 
Bacillus coU, and the staphylococcus and 
streptococcus. A large dose of thyroid 
(1 Gm. per kilo) was given the first 
day, but this was reduced daily. In 
this series, which included 116 examina- 


696 


ANIMAL EXTRACTS (SAJOUS). 


tions, the writer states that he always 
observed that the opsonic power of the 
blood-serum increased very clearly after 
thyroid opotherapy. It was, in fact, 
considerably more than doubled in all 
but one instance, the exception being 
that of an animal in which an emulsion 
of Bacillus coli only increased the op¬ 
sonic power one-half. 

Might the ingestion of any animal 
substance by herbivora not have given 
rise to the increase of opsonic activity? 
The administration of corresponding 
quantities of horse flesh to control 
failed to modify the latter in any way. 
The writer found, moreover, that the 
leucocytes of a normal animal when 
treated in vitro with the serum of an 
hyperthyroided animal showed a dis¬ 
tinct increase of phagocytic activity. 

The second series of experiments had 
for its purpose to ascertain the effects 
of removal of the thyroid on the op¬ 
sonic properties of the blood. The 
serum obtained from 4 dogs at the time 
of the characteristic accidents caused by 
thyroidectomy showed in every instance 
a most evident diminution of opsonic 
power. The same experiments con- 
. ducted in the rabbit gave rise to the 
same results, i.e., he always found a 
marked decline of opsonic power in 
thyroidectomized animals. He noted, 
moreover, that, while traumatism, even 
a musculocutaneous wound, could cause 
in a certain measure a reduction of 
opsonic power, the latter rapidly re¬ 
turns to normal, while it maintains itself 
a very long time at the same level in 
thyroidectomized animals. S. Marbe 
(C.-r. de la Soc. de Biol., vol. Ixiv, 
p. 1058, 1908). 

Briefly (see the present, 1922, status 
of the question by R. W. Wilcox, 
pages 688 and 689), the physiological 
action of thyroid preparations may be 
summarized as follows:— 

1. They enhance oxidation by in¬ 
creasing the inflammability of the phos¬ 
phorus, which all cells, particularly 
their nuclei, contain, and by enhancing 
the functional activity of the adrenals. 


2. Their power to enhance the in¬ 
flammability of cellular phosphorus ex¬ 
tends to pathogenic elements, bacteria, 
their toxins or endotoxins, toxic 
wastes, etc. As such they act as opso- 
nins, and render these pathogenic ele¬ 
ments vulnerable to the immunizing 
action of the blood and its phagocytes. 

THE ACTIVE PRINCIPLE OF 
THYROID. —The thyroid product is 
an “iodized globulin.” As Nothin and 
also White and Davies hold, the action 
of the thyroid secretion resembles that 
of an organized ferment. This finds 
its explanation in the fact that the 
thyroidin, to which this applies, is 
mainly a ferment plus iodine. The 
identity of this ferment suggests itself 
when we consider Baumann’s analyses 
of his thyroidin. Among other tests, 
for example, he found that it was prac¬ 
tically insoluble in ether and chloro¬ 
form; that it was not destroyed by 
digestive ferments, and that it stood a 
temperature of 100° C. These are the 
specific tests of the oxygen-laden adre¬ 
nal product, my adrenoxidase. Again, 

I found that this substance gave the 
tests of the plasmatic oxidase; Lepin- 
ois also found that the thyroid secre¬ 
tion contained an oxidase which gave 
the blue reaction with tincture of 
guaiac. We have seen, moreover, that 
adrenoxidase is a globulin: Oswald 
termed his product “thyroglobulin” and 
described it as an “iodized glob¬ 
ulin.” 

The recent discovery of Kendall of 
crystalline body in the thyroid, he 
termed “thyroxin” has already been 
reviewed on page 693, and its possible 
role in metabolism described. 

The crystalline body containing 
over 60 per cent, of iodine prepared 
'from the thyroid by Kendall, of the 
Mayo Clinic, was tried on cretins and 


ANIMAL EXTRACTS (SAJOUS). 


697 


myxedema patients. The results 
justify the view that this substance 
is to be regarded as a hormone hav¬ 
ing the functions ascribed to the thy¬ 
roid. They very definitely indicated 
that a gain, not a loss, of nitrogen is 
a result of the therapeutic action of 
thyroid; and vice versa, that a loss of 
nitrogen, that is, protein, is due to a 
toxic condition of the gland. Thgy 
showed also that usually too great an 
amount of thyroid is prescribed in 
hypothyroidism. The thyroid of 
obesity depends on a toxic effect, as 
it is accompanied by nitrogen loss. 
It should therefore be discouraged. 
N. W. Janney (Arch. Internal Med., 
xxii, 187, 1918). 

PREPARATIONS AND DOSE. 

—The implantation of a portion of the 
thyroid gland beneath the skin was 
soon superseded by the hypodermic 
method, but the latter presented an¬ 
other drawback, that of requiring the 
constant attendance of the physician. 
Besides this the preparations often 
produced suppuration. The gland it¬ 
self, therefore, administered in the form 
of desiccated powder in tablets or cap¬ 
sules, is preferred by the majority of 
practitioners. This presents also the 
advantage of conforming to the Ninth 
Decennial U. S. Pharmacopoeia {thy- 
roideuM siccufn) made official from 
September 1, 1916. 

The average dose recommended in 
the previous Pharmacopoeia was en¬ 
tirely too large, but this was corrected 
in the last edition. It is now V/i grains 
(0.1 Gm.). 

But much smaller doses grain and 
even less, three times daily may be ad¬ 
vantageously used, even in the adult. 
While small doses enhance metabolism, 
larger doses so stimulate catabolism 
that they cause undue breaking down 
of the fats and tissues. 

If kept up too long, the blood ele¬ 


ments themselves (hemolysis), and 
even the tissues (autolysis) proper, 
may be destroyed. Five- or even 4- 
grain doses—the former dose of the 
U. S. P.—are never indicated, even in 
the treatment of obesity. 

By loading up the circulation with 
toxic wastes, these excessive doses may 
also give rise to tetanoid movements 
and even to true tetany. 

An important feature in this connec¬ 
tion, however, is that the preparations 
of desiccated thyroid on the market 
vary in strength to a considerable de¬ 
gree, and that a small dose of a weak 
preparation may prove practically inert 
in practice. This is due to the fact that 
they have not as yet been standardized. 
This does not apply to an imported 
desiccated thyroid, that of Burroughs, 
Wellcome and Co., which is standard¬ 
ized, each grain (representing about 6 
grains of the fresh gland) containing 
0.02 of iodine in organic combination. 
It is upon this standard that the dosage 
recommended above is based. It is 
available in small tablets of 1, 

1/4, 2 ^ 2 , and 5 grains. 

There is also on the market an im¬ 
ported article termed iodothyrin, a 
milk-sugar triturate of the thyroid 
active principle, 1 Gm. of which repre¬ 
sents 0.0003 Gm. of iodine. The dose 
for adults is given as 10 to 30 grs. (0.6 
to 2 Gm.), and is available in tablet 
form, each containing 5 grains (0.33 
Gm.) of iodothyrin. Its manufactur¬ 
ers claim that, besides possessing the 
advantage of definite strength, it is 
devoid of extraneous matter. It is not 
regarded as efficacious as the desic¬ 
cated gland. It is a convenient prep¬ 
aration for young children, however, 
owing to the fact that it occurs as a 
sweet, whitish powder. 


698 


ANIMAL EXTRACTS (SAJOUS). 


When preparations of thyroid gland 
—which include parathyroid—cannot 
be obtained, a glycerin extract may be 
prepared by divesting a sheep’s gland 
of fat, and macerating it in an equal 
quantity in weight of glycerin twenty- 
four hours. From 2 to 15 minims of 
the extract may be given daily accord¬ 
ing to age. 

Thyroxin was found to have a defi¬ 
nite therapeutic effect in cretinism, 
improvement in the clinical symp¬ 
toms and a gain in nitrogen reten¬ 
tion resulting. The optional daily 
dose was found to be 0.25 mg. (l^so 
grain) hormone iodine, representing 
approximately 0.75 mg. (Yso grain) 
thyroxin, and corresponding to 4 
grains (0.26 Gm.) of thyroid tablets. 
It could thus be demonstrated that 
as a rule too great an amount of thy¬ 
roid is prescribed in hypothyroidism. 
Janney (Arch, of Internal Med., xxii, 
187, 1918). 

UNTOWARD EFFECTS AND 
THEIR PREVENTION.— The dan¬ 
gers attending the use of thyroid prep¬ 
arations depend, to a degree, upon the 
manner in which the remedy is admin¬ 
istered. Beneficial doses, by raising 
the activity of all metabolic processes, 
prove tonic, increase the appetite, the 
strength, and the oxidations, as shown 
by a slight rise in temperature. When, 
however, the dose is too large, a weak, 
rapid pulse and shortness of breath, 
vomiting, cardiac oppression, a feeling 
of tightness around the chest, vertigo, 
and coma may supervene. Excessive 
doses have also caused anorexia, diar¬ 
rhea, malaise, lassitude, and pain in 
the extremities; headache, various 
eruptions, urticaria, transient and pap¬ 
ular erythema and eczema, and, in 
some cases, nervous manifestations; 
neuralgia, delirium, convulsions, delir¬ 
ium of persecution, aphasia, monople¬ 
gia, etc. When dried powder or com¬ 


pressed tablets that are not fresh are 
used, symptoms of ptomaine poisoning 
may be added to those mentioned. 
Hence, the observations that these prep¬ 
arations are more likely to produce 
such effects during the warm weather. 

The best guide is the pulse. Any 
considerable quickening or palpitation 
should lead us to discontinue the drug 
until the cardiac action is again normal. 
There are no dangers in the use of the 
drug, provided we begin with small 
doses, from ^ to 1 grain, and grad¬ 
ually increase, watching the pulse. It 
should never be given to a patient 
who cannot be closely watched. 

In some cases, although no other un¬ 
toward symptom appears, the patient 
loses flesh. This is apt to occur when 
2 grains of the dried gland three times 
daily in the adult is exceeded. 

Chronic poisoning, characterized by 
rapid pulse, emaciation, weakness of 
the limbs, general debility, and mydria¬ 
sis have also been observed in individ¬ 
uals who had undertaken, without med¬ 
ical advice, to treat their corpulency, 
and who had, therefore, subjected 
themselves to excessive doses. 

TREATMENT OF THYROID 
POISONING. —As a rule, cessation 
of the use of thyroid preparations ar¬ 
rests the untoward effects. When such 
is not the case, however, arsenic, as 
shown by Mabille, antagonizes the 
toxic phenomena. Fowler’s solution, 
from 3y2 to 5 drops three times daily, 
suffices in most instances to arrest all 
morbid effects. 

Mabille’s observation that arsenic ob¬ 
viates the unpleasant symptoms excited 
by thyroid preparations were confirmed 
by Ewald. In 5 cases of idiopathic goiter, 
in 1 case of obesity, and 1 of infantile 
myxedema, iodothyrin was given m pro¬ 
gressive doses of from 3% to 30 or 38^ 
grains daily. At the same time arSenic 


ANIMAL EXTRACTS (SAJOUS). 


699 


was given, either in pills or as Fowler’s 
solution, in doses increasing proportion¬ 
ately to the iodothyrin of %4 to M .0 or 
even grain daily. 

Although the 7 cases took respectively 
231, 111, 86, 320, 108, 296, and 125 iodo¬ 
thyrin tabloids, containing nearly 4 grains 
each, beyond occasional increased fre¬ 
quency of the pulse no symptoms of thy- 
roidism appeared, so that the course could 
be continued uninterruptedly. Arsenic, 
therefore, appears to suppress thyroidism 
with greater certainty than atropine does 
iodism, and it is possible to give iodothy¬ 
rin safely in doses and for a period 
capable of producing definite therapeutic 
effects. 

The addition of a cardiac tonic, 
preferably adonidin, to thyroid is 
recommended whenever the latter 
preparation is to be used for any 
length of time. The following for¬ 
mula is employed:— 


B Sodium cacodylate . ^/^oo gr. 

Adonidin . kw gr. 


Thyroid gland (dry powder). 1 gr. 

For 1 compressed tablet. When 
fresh adonidin cannot be obtained 
(its price is exceedingly high), caffeine 
may be substituted in doses of % 
grain. Thyroid therapy will receive a 
new stimulus as soon as the medical 
profession appreciates the fact that 
the addition to the thyroid of proper 
amounts of arsenic and a cardiac 
remedy will render the medication 
more efficient and deprive it of all or 
nearly all its deleterious effects. 
Heinrich Stern (American Medicine, 
Jan., 1910). 

THERAPEUTICS.— The many 
disorders in which thyroid prepara¬ 
tions have been recommended (“nearly 
all the chronic and many of the acute 
troubles known to humanity,” as one 
author remarks) have naturally in¬ 
spired considerable mistrust as to their 
actual therapeutic value. Gradually, 
as the harmfulness of large doses as¬ 
serted itself and the physiological role 
of the thyroparathyroid apparatus be¬ 


came unraveled, however, their indi¬ 
cations became better defined. It 
may now be said that in sharp con¬ 
trast with the empirical methods of 
the past thyroid preparations, when 
employed intelligently, are of great 
value in many disorders, both acute 
and chronic, mainly through their po¬ 
tent infiuence over metabolism due to 
the contained organic iodine. Recent 
ex])erimental and clinical investigations 
have well shown that the thyroid acts 
more powerfully in accelerating metab¬ 
olism than any other known agency. 

The writer’s experiments empha¬ 
size the extraordinary affinity of the 
thyroid tissue for iodine. As high 
as 18.5 per cent, of a given intake of 
iodine by mouth may be recovered 
from a thyroid whose ratio to the 
body weight is as 1:687. Again, 
maximum thyroid effects may be in¬ 
duced by minimum amounts of 
iodine. The amount of a given in¬ 
take absorbed depends, for the most 
part, on the size of gland and the 
existing degree of hyperplasia or the 
degree of saturation with iodine at 
the time of its administration. 
Marine (Jour. Biol. Chem., Oct., 1915). 

Basal Metabolism.—This method 
of ascertaining the degree of activity 
of the thyroid gland has recently 
received considerable experimental 
and clinical support. 

As it is reviewed under Graves’s 
disease, it may be recalled that while 
the basal metabolism of a normal in¬ 
dividual varies but about 10 per cent., 
any greater variation is of endocrine 
origin, the thyroid furnishing the 
widest variations. 

The writer found in a case of ex¬ 
ophthalmic goiter that the standard 
of metabolism reached 80 per cent, 
above normal, and in a myxedema 
patient 40 per cent, below normal. 
Krogh (Ugeskrift f. Laeger, Dec. 29, 
1916). 




700 


ANIMAL EXTRACTS (SAJOUS). 


In the light of the functions attrib¬ 
uted to the thyroid secretion in the 
foregoing pages, it governs tissue me¬ 
tabolism by rendering all phosphorus¬ 
laden cells susceptible to oxidation. 
When, therefore, the thyroid principle 
is deficient in the body, both phases of 
metabolism—including,of course, that 
of carbohydrates—the building up and 
the breaking down of tissues, are 
correspondingly inhibited. The most 
exaggerated expressions of this condi¬ 
tion are, as is well known, the syn¬ 
dromes known as myxedema and cre¬ 
tinism. The characteristic symptoms 
of these disorders e?iemplify clearly 
deficient metabolid activity and its 
consequences. In myxedema we have, 
among other symptoms, for example, 
the low temperature, 95.5° F. in some 
instances, both in the mouth and rec¬ 
tum; great sensitiveness to cold, 
reduction of the urea output—some¬ 
times to 50 per cent, of the normal— 
cyanosis of the lips, ears, and extrem¬ 
ities on exposure to slight cold„ and 
many secondary results of defi¬ 
cient metabolic activity, anemia with 
marked pallor, general relaxation 
of the arteries, muscular weakness, 
mental torpor and vertigo, and the cu¬ 
taneous anesthesia. In the cretin, we 
have, besides, all the phenomena of ar¬ 
rested development, both physical and 
mental, as shown by the dwarfed body 
and the idiocy. 

Hypothyroidia, or Hypothyroid¬ 
ism.—This is a condition akin to the 
above, but much less marked, fre¬ 
quently met in practice. The thyroid 
apparatus supplies a part only of that 
required by the tissues, and the result¬ 
ing phenomena recall closely some of 
those observed both in myxedema and 
cretinism: chilliness and subnormal 
temperature, coldness of the extremi¬ 


ties and sensitiveness to cold; fatigue 
on slight exertion; constipation with 
tendency to tenesmus; frequent at¬ 
tacks of migraine, “sick headaches’" 
with nausea, vomiting, etc., and other 
periodic manifestations of autointox¬ 
ication—due to inadequate reduction 
of waste products and their retention 
in the blood. The skin taking part in 
the process of elimination, urticaria 
and eczema are frequently observed, 
while transitory edemas of the brow, 
around the eyes, and sometimes of the 
face, even in the absence of albumi¬ 
nuria or casts, point to renal fatigue. 
Enuresis is commonly observed in 
children of this type and may persist 
to adult age. The patient is subject to 
frequent catarrhal disorders of the re¬ 
spiratory passages, usually ascribed to 
colds, but due mainly to vascular and 
glandular relaxation. A tendency to 
early alopecia, including the eyebrows 
(especially the outer third), is also 
noticeable—a sign of deficient general 
nutrition which coincides with a 
marked proclivity to early senility. 

In . women the menstruation appears 
late, owing to retarded development, 
and there is a proclivity to metrorrha¬ 
gia due to laxity of the muscular coats 
of the uterine arterioles, while pelvic 
disorders are apt to occur owing to de¬ 
ficient support of the uterus, lack of 
tone in its muscular elements. Leucor- 
rhea is also frequent, owing to relaxa¬ 
tion of the glandular elements of the 
whole genital tract. Such women con¬ 
ceive readily, but abortion is very fre¬ 
quent among them; if the fetus is 
carried to the normal period, they have 
little or no milk. Children born of 
such mothers make up the largest 
number, if not all, the cases of cretin¬ 
ism, rickets, harelip, cleft palate, and 
other malformations usually ascribed 


ANIMAL EXTRACTS (SAJOUS). 


701 


to hereditary influence. We are deal¬ 
ing simply with deficiency of the iodine 
in organic combination which the 
thyroparathyroid glands supply to the 
organism to sustain their intrinsic 
metabolism, i.e., their vital activity. 

Hertoghe has urged the importance 
of the maternal thyroid on the develop¬ 
ment of the fetus, hypothyroidia from 


fault be added tuberculosis, hereditary 
syphilis, alcoholism, inanition, saturn¬ 
ism, or diabetes, the child will show un¬ 
doubted signs of these taints, and will 
probably be a myxedematous cretin, 
with signs of rickets and achondro¬ 
plasia, and to this cause may be assigned 
such malformations as harelip, cleft 
palate, bony deformities, hypospadias, 
or undescended testicle. Should the 
maternal taint be but slight, the child 



Adipositas (8 months old). Weighs 36 pounds. (Sheffield.) 


any cause favoring cretinism in the 
child. It also promotes sterility, the 
use of thyroid gland being often fol¬ 
lowed by pregnancy. 

Hypothyroidia is often the cause of 
obesity in children, as well as in adults 
(see annexed cuts), and of the cold 
feet and hands and other phenomena 
observed in fat, pasty children. 

If the mother has at her disposal suf¬ 
ficient store of thyroid secretion, the 
child does well; but if there is thyroid 
insufficiency, and especially if to this 


will merely be very backward, which is 
a matter of small amount in boys, and 
if after a time righted by the thyroid 
equilibrium being established; but in 
girls menstruation is late in being estab¬ 
lished; uterine retroflexion is frequent; 
the chest is undeveloped. 

The author has often seen women 
nearing 40 years of age who are fat 
and whose menstrual flow is excessive 
take thyroid extract in order to reduce 
their obesity. He has often seen the 
menstrual flow in these women become 
modified, their stoutness decrease, and 
the women find themselves pregnant. 






702 


ANIMAL EXTRACTS (SAJOUS). 


when they had for a long time given up 
all hope of ever being so again. He has 
often by means of thyroid extract 
brought to a successful end a preg¬ 
nancy in women who have repeatedly 
miscarried. It is often noticed that 
in adults incontinence of the urine 
can be stopped by rest in bed. This 
comes about from the fact that, while 
resting in bed, the patient is subject- 


artificial feeding, these signs become 
more pronounced, with eczema, urti¬ 
caria, tardy dentition, etc. It seems evi¬ 
dent that nurslings receive in mother’s 
milk some of the products of the 
mother’s thyroid functioning. The 
physiological hypothyroidism of the new¬ 
born may assume pathological propor¬ 
tions; any derangement in thyroid 
functioning on the part of the mother 



Adlpositas. Same case, back view. (Sheffield .) 


ing his tissues to large'doses'of thy¬ 
roid secretion. In the case of a 

i 

pregnant woman the increase of 
thyroid secretion often becomes excess¬ 
ive during the pregnancy, and the 
woman suffers from the symptoms of 
excessive thyroid secretion. Hertoghe 
(Bull, de I’Acad. Royale de Med. Bel¬ 
gique, April 27, 1907). 

Thyroid insufficiency is the cause of 
many of the phenomena noted in young 
infants, such as a tendency to obesity, 
to transient edema, cold feet and hands, 
scanty and brittle hair, vasomotor dis¬ 
turbances, vomiting, somnolency, and 
slight resistance to infections. With 


or wet-nurse may lead to severe symp¬ 
toms of hypothyroidism in the infant. 
In several instances in the writer’s 
experience infants became myxedema¬ 
tous when the mothers had goiter. In 
other cases, the healthy infants of 
healthy parents became myxedematous 
when they had a wet-nurse with goiter. 
All these children were cured with 
thyroid treatment and change of nurse. 
Experimental research with goats has 
confirmed the actual occurrence of 
transmission of thyroid secretion by 
the placenta and in the milk. Concetti 
(Annales de med. et chir. infantiles, 
Aug. 15, 1909). 




ANIMAL EXTRACTS (SAJOUS). 


703 


The rudimentary forms of myx¬ 
edema or hypothyroidism in children 
are particularly liable to escape recog¬ 
nition, while thyroid treatment in 
time is almost a certain cure. In a 
case of this kind a boy of 6 had not 
grown in the last two years, but 
seemed otherwise normal, although 
not particularly bright. Under cau¬ 
tious thyroid treatment by the end 
of eighteen months he had grown 11 
cm., nearly 4^2 inches. In 2 other 
cases the myxedema developed, after 
severe measles or mumps, with acute 
thyroiditis in the latter case. The 
thyroid treatment ordered was soon 
abandoned by the family, and the 
child developed pronounced myx¬ 
edema, but after two years it spon¬ 
taneously subsided. In a fourth case 
the myxedema developed after a 
severe fall over a balustrade, the 
throat in front bleeding from the in¬ 
jury. Thyroid treatment promptly 
cured the child. “Pasty” children, 
fat, pale, and flabby, may be suflfering 
from hypothyroidism and require thy¬ 
roid treatment. Stoeltzner (Jahr- 
buch fiir Kinderheilkunde, Aug., 
1910). 

Thyroid insufficiency often under¬ 
lies irregular, delayed, and erratic 
dentition and decayed teeth in chil¬ 
dren. Administration of thyroid is 
markedly effective especially in de¬ 
layed dentition and children border¬ 
ing on cretinism. The writer in¬ 
variably starts to regulate the teeth 
of a young child by giving thyroid. 
M. C. Smith (Boston Med. and Surg. 
Jour., Oct. 19 and Nov. 9, 1916). 

The writer found that in some 
cases of hypothyroidia, in which the 
administration of animal thyroid 
preparations only partially controlled 
the symptoms, they were almost 
completely relieved by human thy¬ 
roid extracts. S. P. Beebe (N. Y. 
Med. Jour., civ, 445, 1916). 

Hypothyroidia, in so far as nutri¬ 
tion is concerned, may be defined, 
therefore, as that condition of the body 
in which, owing to deficient production 


of the thyroparathyroid secretion, cel¬ 
lular metabolism is slowed sufficiently 
to inhibit more or less all functions. 
Hence, the value of thyroid prepara¬ 
tions in infantile marasmus. 

In infantile wasting the writer gives 
thyroid in a diluted milk and cream 
mixture with sodium citrate, 1 or 2 
grains to the ounce of milk. In a day 
or two cream is gradually added, a 
teaspoonful to the feeding bottle. 
Out of 80 cases thus treated 72 were 
infants under 9 months and their his¬ 
tory was simply one of wasting. The 
other 8 had a wasting supervening 
on some acute diseases: 63 cases did 
well; 5 cases presented syphilitic 
histories in which wasting was a 
marked symptom. Mercury was first 
given and later thyroid. Three 
immediately gained and eventually 
recovered. In older children the re¬ 
sults have also been favorable, ex¬ 
cept when tuberculosis was present. 
In children under 9 months, the 
author began with H grain of dried 
thyroid once daily. Larger doses 
often seemed to induce a diarrhea. 
In the giving of thyroid it is advis¬ 
able to test the stools frequently to 
see whether they are acid or alkaline. 
In case acidity is found the bicar¬ 
bonate of soda may be given three 
times daily, and when the natural 
alkalinity of the stools is restored the 
thyroid will begin to exert its bene¬ 
ficial results. No grave symptoms 
followed the thyroid therapy. In 6 
cases a punctiform rash appeared, 
confined in 2 cases to the front of 
the chest. It was evanescent and 
disappeared without treatment in the 
course of twelve to twenty-four 
hours. In only 1 case was it neces¬ 
sary to stop the thyroid (three days) 
in order to cause the rash to dis¬ 
appear. J. W. Simpson (Brit. Med. 
Jour., April 30, 1910). 

Its administration to mothers who 
have not enough milk for their babies 
has, in the writer’s practice, with one 
exception, been followed by an in¬ 
crease in the flow, making it possible 
to get along without artificial feed- 


704 


ANIMAL EXTRACTS (SAJOUS). 


ing where such feeding had been 
necessary with former children and 
would have been necessary in these 
cases, as shown by decreased flow 
whenever the thyroid was withheld. 
E, W. Demaree (Western Med. Rev., 
May, 1910). 

The symptoms of typical hypothy¬ 
roidism, besides the adiposis, are 
scanty or absent menstruation, drow¬ 
siness, slow pulse, dry skin, local 
pufflness and perhaps slow mentality. 
The writer cautions against the. care¬ 
less use of thyroid. It should be 
added to the list of poisons and never 
sold unless with physician’s prescrip¬ 
tion, It is potent for harm, and a 
little too much may push a wavering 
thyroid gland to hypothyroidism. O. 
T, Osborne (Jour. Amer. Med. As¬ 
soc., Nov. 2, 1912). 

The writer met with a case of 
double pneumonia and pleural collec¬ 
tion which was followed by the fol¬ 
lowing clinical syndrome: intense 
abdominal pain, constipation and 
slight meteorism, profuse sudation, 
normal temperature and a slow, ir¬ 
regular pulse. At autopsy the writer 
found a hemorrhage in both supra- 
renals; the medullary substance was 
entirely destroyed in 1, and greatly in¬ 
volved in the other. The cortex of 
the glands was preserved. The 
writer points out the concordance 
between the clinical signs offered and 
the physiological data known, which 
show that the disturbances arising in 
this case resulted from a lack of tonus 
of the sympathetic, that is to say, 
from an adrenalin insufficiency. Low- 
enthal (Berl. med, Woch., Nov, 25, 
1918). 

In contrast with this condition, and 
exemplifying clearly what we are to 
expect from thyroid preparations, is 
the opposite condition—hyperthyroidia. 

Hyperthyroidia, or Hyperthyroid¬ 
ism.—The opinion of Mobius that ex¬ 
ophthalmic goiter or Graves’s disease 
is due to overactivity of the thyroid 
(treated in full in the fifth volume) 


has steadily gained ground. But this 
imposes the necessity of establishing 
clearly the diagnosis of this disease, 
for there are many disorders that are 
due to thyroid overactivity, the so- 
called “larval” or “aberrant” types, 
the “formes frustes” of the French, 
or “pseudo-Graves’s” disease, which 
should not be confounded at all with 
true exophthalmic goiter, since the ac¬ 
tive or erethic stage of the latter is 
aggravated by the use of thyroid prep¬ 
arations, while the “pseudoforms” are 
benefited by these agents. This does 
not, however, militate against the fact 
that exophthalmic goiter and all the 
above-mentioned subtypes are expres¬ 
sions of thyroid overactivity, or hyper¬ 
thyroidism. In all we meet, more or 
less defined—in proportion with excess 
of thyroid secretion produced—the 
same group of phenomena, all of which 
can readily be explained by excessive 
tissue metabolism and its consequences. 

Tests.—Loewi in 1908 found that the 
instillation of 1: 1000 solution of adrenalin 
in the conjunctiva produced dilatation of 
the pupil with abnormal readiness when 
hyperthyroidia was present owing to the 
increased irritability of the dilator fibers 
of the iris due to the disease. Numerous 
observers have confirmed these observa¬ 
tions. 

The best adrenalin test is that of E. 
Goetsch (N. Y. State Jour, of Med,, July, 
1918) based on the fact that a patient suf¬ 
fering from hyperthyroidism is hypersen¬ 
sitive to adrenalin. A hypodermic syringe 
with a fine needle is used to inject 0.5 c.c. 
(8 minims) of the 1: 1000 solution of ad¬ 
renalin into the deltoid region subcutane¬ 
ously. The positive reaction is character¬ 
ized by an early rise of blood-pressure and 
pulse varying from 10 to 50 and normally 
proportional to the degree of thyroid in¬ 
toxication present. There occur also the 
symptoms, such as asthenia, tremor, throb¬ 
bing, vasomotor changes, apprehension 
and nervousness, which characterize a mild 
case, or an increase of previous symptoms. 


ANIMAL EXTRACTS (SAJOUS). 


705 


Lymphocytosis indicates a patho¬ 
logical state due to toxic influences 
from the thyroid. It is a symptom 
that cannot be simulated, and has 
often proved of decisive value in dis¬ 
tinguishing between functional or 
organic heart disease. Instillation of 
epinephrin in the eye also causes 
mydriasis that is prompt, marked and 
lasting for several hours, when the 
thyroid is functioning abnormally. 
Curschmann (Med. Klinik, Mar. 5, 
1916). 

During the great war, many cases of 
hyperthyroidism were observed among 
the troops, due to the intense stress, 
and exertion to which they were sub¬ 
jected. 

Hyperthyroidism is seen very fre¬ 
quently in the military service age, 
the young and middle aged adults. 
Owing to its symptoms, it interferes 
with a soldier’s duties; it is of great 
importance to diagnose this condi¬ 
tion, and, if it exists, to what degree. 
This can be accomplished by means 
of galvanopalpation in which a posi¬ 
tive diagnosis can be made when gal- 
vanohyperesthesia and a high degree 
of reaction of the blood-vessels is ob¬ 
tained. Max Kahane (Wiener klin. 
Woch., Feb. 11, 1915). 

The most striking feature of cases 
of hyperthyroidia in the recruit in 
nearly every instance is tachycardia. 
This is the sign because of which 
most of the cases report to the regi¬ 
mental medical officer or on which 
they apply for exemption or dis¬ 
charge. It is constant in practically 
all examples of the syndrome, though 
it varies very greatly in degree. It is 
present alike in recruits presenting 
themselves for initial examination, in 
those who report later, and after con¬ 
siderable drill and army routine may 
have further served to upset the men¬ 
tal, emotional and circulatory equi¬ 
librium of these patients. 

The tachycardia is rarely accom¬ 
panied by arrhythmia even in cases of 
very marked degree, and polygraphic 
studies, except in instances compli¬ 
cated by other vascular conditions. 


show, aside from rapidity, few signs 
of abnormal action, except that in the 
same case there is under varying con¬ 
ditions usually great variation in the 
rate of systoles. Practically always 
the rate is increased by exercise, 
though there are exceptional cases in 
which, as in ordinary palpitation, ex¬ 
ercise may slow the rate, especially 
when the attention is thereby dis¬ 
tracted; but speed of action is* even 
more constantly accelerated by ex¬ 
citement and disturbing emotional 
factors. 

Closely associated with tachycardia 
is an obvious and subjective throb¬ 
bing of the superficial vessels, notably 
of the carotids, of the brachials and 
even of the femorals, while that of 
the aortic, in moderately thin persons, 
is also quite evident. Harlow Brooks 
(Amer. Jour. Med. Sci., Nov., 1918). 

The thyroid was found enlarged in 
about two-thirds of recruits exam¬ 
ined in whom tachycardia existed, 
sufficiently in some to constitute 
true goiter and to produce pres¬ 
sure dyspnea. In most of these an 
ancestral history of goiter, particu¬ 
larly on the maternal side, was given. 
Exophthalmos was present in cases 
of long standing, sufficiently so, in 
some instances, to have produced 
conjunctival hyperemia and desicca¬ 
tion. In some, the exophthalmos had 
developed suddenly. Virtually all pa¬ 
tients were rapid and large eaters, 
but they bore acute infections badly, 
while tobacco produced in them 
more serious symptoms than in the 
average smoker. 

This symptom, which includes all 
the cardinal signs of Graves’, was 
observed chiefly among men belong¬ 
ing to nationalities in which the emo¬ 
tional element is common: the 
Hebrews, Italians, and Irish, the fre¬ 
quency following the order named. 
The negroes, least of all races, 
showed a predilection to the dis¬ 
order. 

In civil life emotional stress of any 
kind, fright particularly in the course 
of accidents accompanied by trau¬ 
matisms or blows, car or train dis- 


1—45 


706 


ANIMAL EXTRACTS (SAJOUS). 


asters, mental distress, worry, violent 
emotions, etc., are familiar causes of 
Graves’ disease. A personal case due 
to an accident and rapidly proceed¬ 
ing to recovery under medical treat¬ 
ment, recurred at once after a second 
accident, though the patient had suf¬ 
fered no traumatism. C. E. de M. 
Sajous (Penna. Med. Jour., Jan., 
1919). 

Untoward Effects.—When large or 
excessive doses of thyroid preparations 
are administered, there occurs: a rise 
of temperature, a feeling of abnormal 
warmth; tachycardia due to excessive 
excitability of the heart muscle; pains, 
trembling owing to a similar condition 
of all muscles; sweating due to over¬ 
activity of the sweat glands; vomiting 
and diarrhea owing to abnormal irri¬ 
tability of their gastric and intestinal 
neuromuscular supply. Excessive me¬ 
tabolism involving the production of a 
surplus of wastes, the kidneys are 
overburdened and overactive, and the 
cutaneous emunctories likewise, the lat¬ 
ter causing pruritus and a papular 
eruption, beginning, as a rule, over the 
scapulae. As in Graves’s disease, hyper¬ 
thyroidism and excessive doses of thy¬ 
roid may produce apparent protrusion 
of the eyeballs, the palpebral muscles 
being retracted owing to their abnormal 
contractility and changes in carbohy¬ 
drate metabolism. 

In a study of 27 cases of hyperthy¬ 
roidism, excess of sugar in the blood 
was found to be a very common ac¬ 
companiment of the latter condition, 
occurring in 90 per cent, of instances 
in the moderate and severe types of 
cases. Glycosuria, either spontaneous 
or alimentary (100 Gm. of glucose 
having been given), was an equally 
constant symptom.- Alimentary hy¬ 
perglycemia and glycosuria were even 
found not uncommonly in the very 
mild cases. Marked diagnostic sig¬ 
nificance is attached to the lowered 


carbohydrate tolerance in hyperthy¬ 
roidism, its presence being highly 
suggestive where alcoholism, fever, 
asphyxia, neurasthenia, and the vari¬ 
ous other ductless gland disorders 
can be excluded. H. Rawle Geyelin 
(Arch, of Internal Med., Dec., 1915). 

The writer describes cases in which 
the condition of hyperthyroidism was 
the cause of the carbohydrate toler¬ 
ance being destroyed. His first case 
presented the classical symptoms of 
the 2 diseases, diabetes mellitus and 
exophthalmic goiter. Not suspecting 
that the glycosuria might be related 
to the coexisting Graves’s disease, 
the latter was regarded as the lesser 
of the two evils and treatment directed 
entirely toward the former. A total 
restriction of carbohydrates was un¬ 
availing in securing sugar-free urine. 
While the percentage was reduced, 
the sugar content of the blood re¬ 
mained unchanged. The patient fin¬ 
ally died in coma. 

Before“the second patient with the 
same syndrome was encountered, the 
author having acquired some experi¬ 
ence with the boiling water injec¬ 
tions of Porter, applied this method 
to his second case together with the 
usual dietary treatment of diabetes. 
The goiter was injected daily, about 
60 minims (3.75 c.c.) of boiling water 
being used. In 4 days a carbohydrate 
tolerance was gained, increasing with 
each succeeding injection till, finally, 
with extirpation of the goiter, normal 
tolerance was completely restored. 

Reference is made to the work of 
Sainton and Gastaud of Paris, and 
the statistics given by them show the 
frequency of diabetes in exophthalmic 
goiter as 3 in 100 cases. Clinically, 
diabetes occurring in the course of 
Graves’s disease is manifest in two 
ways: (1) as a temporary or slight 
glycosuria with the usual symptoms 
of diabetes only present in a trifling 
degree, (2) as a well-established con¬ 
dition, with all the characteristic 
symptoms present, the latter fre¬ 
quently even dominating the clinical 
picture as a whole. The possibility 
of the adrenals participating in such 


ANIMAL EXTRACTS (SAJOUS). 


707 


a glycosuria is considered, owing to 
the thyroido-adrenal origin of exoph¬ 
thalmic goiter as taught by the Vienna 
school. This teaching is based on the 
theory that a relation exists between 
the thyroid, pancreas, and chromaffin 
system. J. C. O’Day (Surg., Gynec. 
and Obstet., Feb., 1916). 

A case of thyroidism in an infant from 
administration of thyroid extract to the 
mother, a woman aged 34 who had ex¬ 
ophthalmic goiter, was observed by Bram- 
well. On December 24th thyroid extract 
(two 5-grain tabloids daily) was adminis¬ 
tered to the mother. On January 1st the 
child had been sweating profusely for sev¬ 
eral nights. It was looking ill and was 
sleepless. It had vomited every morning 
for three days. The extract was conse¬ 
quently stopped for five days. The child 
immediately improved, and on January 
4th was quite well. On the 9th, thyroid 
extract was again given to the mother. 
The next day the child vomited, was again 
restless, did not look well, and sweated 
profusely, etc. The child was weaned and 
after this remained perfectly well. 

The administration of thyroid gland 
substance, or thyroid extract, is 
capable, if given in sufficient amount, 
of inducing a toxic state which in al¬ 
most every essential is similar to 
Graves’s disease. An artificial state 
of hyperthyroidism is thereby pro¬ 
duced, which duplicates almost in full 
the morbid syndrome. Even the 
characteristic exophthalmic symp¬ 
toms have been observed after thy¬ 
roid feeding by Auld, Beclere, -and 
others, and Edmunds was able to in¬ 
duce proptosis, widening of the pal¬ 
pebral fissure, and dilatation of the 
pupils in six monkeys by this means, 
even after excision of a portion of 
the cervical sympathetic. A. R. 
Elliott (Amer. Jour. Med. Sci., Sept., 
1907). 

To determine the relation between 
the thyroid and the reproductive life 
of women, the writers studied 1000 
cases, 550 being primiparae and 450 
multiparae. In these 97 cases of en¬ 
larged thyroid were found, i.e., in 64 
primiparae and in 33 multiparae. A 


family history of goiter was present 
in 8 cases (7 primiparae, 1 multiparae). 
In 6 primiparae there was a history 
of menstrual disturbance. Hyperthy¬ 
roidism was present in varying de¬ 
grees in 7 cases and probably in 1 
other case, although there was no 
palpable thyroid in this case. Of the 
whole series of thyroid enlargements 
20 cases had already been known to 
have some degree of goiter before 
pregnancy; 30 cases developed during 
the pregnancy; while 47 cases were 
doubtful. Markoe and Wing (Bull. 
Lying-in Hosp. of City of N. Y., 
Nov., 1912). 

Referring to juvenile hyperthy- 
roidia, the writer states that in a 
period of 8 years there have been 
1512 patients operated upon at the 
Mayo clinic for exophthalmic goiter. 
Of these but 5 were under 10 years 
of age. In each there was a firm, 
noticeably enlarged thyroid appar¬ 
ently hyperplastic to the touch. The 
following symptoms were noted: 
vasomotor disturbance of the skin in 
1, tremor in 3, mental irritability in 

4, tachycardia in 5, exophthalmos in 

5. All the other features observed 
in the disease in adults participate in 
the vigorous activities of their asso¬ 
ciates without apparent cardiac or 
muscular distress, while none of them 
even approached the crisis so fre¬ 
quently seen in adults. W. H. Lewis 
(St. Paul Med. Jour., Feb., 1914). 

The writer found signs of exces¬ 
sive or perverted functioning of the 
thyroid as the main disturbance in 66 
of his first 600 patients in the Posen 
military hospital; in 420 others it 
formed part of the clinical picture. 
In the 66 cases of actual thyrosis, 11 
presented gastro-intestinal symptoms 
as the principal disturbance and 
these were manifest also in 64 of the 
group of 420. Thus gastro-intestinal 
disturbance was evident in one-sixth 
or one-seventh of all the cases. It 
was mainly in the form of gastral- 
gia, loss of appetite, eructations and 
sometimes a tendency to vomit. In 
34 of the group of 66 there was an 
unmistakable tendency to goiter, and 


708 


ANIMAL EXTRACTS (SAJOUS). 


in 254 of the group of 420 mentioned 
above the thyroid could be palpated. 
Among the total 486 men with thy¬ 
roid symptoms signs of an apical 
process were found, probably of 
tuberculous origin, in 210 cases. The 
writer warns expressly against iodine 
when there is a possible tendency 
to thyrosis. Caro (Deut. med. 
Woch., Aug. 19, 1915). 

Irritable heart, now so prevalent 
among troops, is almost invariably 
associated with hyperthyroidism. The 
X-ray is the most satisfactory 
method of treatment. The thyroid 
gland should be exposed to a full 
Sabouraud dose filtered through 1 or 
2 mm. of aluminum each week until 
the desired degree of destruction and 
reduction in activity has been at¬ 
tained. Along with this treatment 
there should be the usual enforced 
rest and building up process. The 
usual period required for restoration 
to health is about 2 months. F. A. 
Stoney (Lancet, Apr. 8, 1916). 

With the pathogenesis of these two 
syndromes clearly defined, the various 
disorders in which thyroid prepara¬ 
tions are indicated suggest themselves, 
viz., those in which any of the signs of 
/ty/>othyroidism are more or less dis¬ 
cernible. The pathogenesis of hyper¬ 
thyroidism being also apprehended, the 
limitations of thyroid treatment also 
appear: the doses utilized should be 
adjusted in each case to the degree of 
hypothyroidism that is present. 

The medical treatment of hyper¬ 
thyroidism, to be successful, requires 
a careful study of each patient. A 
simple diagnosis followed by the 
more or less perfunctory injection of 
antithyroid serum will in a small 
percentage of cases be followed by 
favorable relief, but to restore the 
patient to complete good health re¬ 
quires a careful analysis of the con¬ 
ditions in each individual. The degree 
to which each individual patient is 
subjected to these measures is a mat¬ 
ter that can be determined only by 


the individual conditions in each case. 

1. Rest; physical, mental, emotional. 

2. Diet; rigid meat-free diet, and ex¬ 
clusion of all forms of stimulation, 
such as tea, coffee, and alcoholics. 3. 
Administration of antithyroid serum. 
4. Clearing up of all chronic affec¬ 
tions. 5. Maintenance of hygienic 
conditions of the intestinal tract. 6. 
The judicious administration of small 
doses of iodine, always in the form 
of potassium iodide. This agent is 
not indicated in all cases, and is used 
only when the intense activity has 
been controlled. 7. The proper use 
at the right period of the treatment 
of suitable doses of X-ray. 8. The 
administration of neutral hydrobro¬ 
mide of quinine in a small percentage 
of patients during the later periods 
of treatment. 

Hyperthyroidism is not exclusively 
a surgical condition, although enthus¬ 
iastic surgeons so classify it. The 
operated patient is by no means well 
and needs long continued medical 
treatment to make a complete recov¬ 
ery. Beebe (Interstate Med. Jour., 
Feb., 1918). 

Cretinism.—This condition repre¬ 
sents the extreme type of hypothyroid¬ 
ism in the young. The value of thyroid 
gland is such in this distressing disor¬ 
der that it may be regarded as a specific 
—the only agent, in fact, which influ¬ 
ences it at all. The earlier it is used, 
however, the better the results; hence, 
the-importance of early signs of the dis¬ 
ease, the most prominent of which are 
in infants (see article on “Cretinism’’), 
enlargement of the tongue and of the 
thyroid, myxedematous swelling, arrest 
of growth, delay in learning to speak 
and walk, relative deficiency of intelli¬ 
gence, dryness and scaliness of the skin, 
scantiness of the eyebrows and eye¬ 
lashes, pufifiness of the lids, and facies 
of old age. 

The enlargement of the tongue and 
of the thyroid are the most positive 
signs of cretinism in the infant. The 


ANIMAL EXTRACTS (SAJOUS). 


709 


shape of the nose and the complexion 
are not characteristic at this early 
stage, and the myxedematous swell¬ 
ings are not observed until after the 
end of the first year. Early diagnosis 
of acquired cretinism is still more 
difficult. Backwardness in learning 
to walk and talk is the most reliable 
sign. In the endemic regions the 
parents are now being educated to 
watch for the early signs. Von 



Case of cretinism. Result of four months’ 
approaching: nor 


nitrogenous foods being more perfectly 
assimilated, .the nitrogen excretion rises 
—sometimes beyond that ingested. 
There is loss of weight owing to ab¬ 
sorption and excretion of the excess of 
fluids in the tissues—an effect accom¬ 
panied by marked thirst—in some 
cases, as observed by Marie, and in¬ 
creased activity of the kidneys. The 



treatment. Growth, 4 Inches. Intellect 
mal. {Moore.) 


Jauregg (Wien. klin. Woch., Jan. 10, 
1906). 

A comparison of the metabolic ac¬ 
tivity between a cretin over 3^4 years 
old and two normal infants 8^2 months 
and 10 months old, showed that it was 
25 per cent, lower in the cretin than 
in the two infants. Talbot (Amer. 
Jour. Dis. of Child., vol. xii, p. 145, 
1916). 

Soon, sometimes within a few days, 
the effects of whatever preparation is 
used begin to appear: the appetite in¬ 
creases, the temperature rises, and. 


red corpuscles and hemoglobin are 
simultaneously increased. 

The wrinkles and edema disappear; 
the harsh, dry skin becomes soft, 
smooth, and moist; the hair from 
coarse and thin becomes thick and fine. 
Growth is resumed, and proceeds with 
great rapidity in children, sometimes at 
the rate of one inch per month. They 
do not, as a rule, however, grow tall. 
The brain responds more slowly, but 
considerable intelligence is gained in 
most instances, at times even that of 









710 


ANIMAL EXTRACTS (SAJOUS). 


an averag'e child. The later in life 
cretinism develops, the better are the 
chances of improvement in this direc¬ 
tion ; occasionally none is observed. In 
other particulars, all degrees of cretin¬ 
ism, especially in sporadic cases, may 
be said to be improved, the best results 
being obtained in young children. 

Series of nearly 100 cases in which 
three years and more have passed 
since treatment was commenced. All 
degrees of cretinism and all ages 
were unmistakably benefited by the 
treatment, but the best results were 
obtained with the younger children. 
Complete cure was the rule in the 
milder cases, without serious impair¬ 
ment of the hearing, when treatment 
was begun in early infancy (at 6 
weeks in 1 case). Von Jauregg 
, (Wien. klin. Woch., Jan. 10, 1906). 

Since 1905, the Austrian govern¬ 
ment has been supplying thyroid tab¬ 
lets free of charge in seven endemic 
foci of cretinism with medical inspec¬ 
tion twice a year. About 108,600 tab¬ 
lets were thus distributed in 1907, and 
157,900 in 1908; the number of per¬ 
sons taking them was 1011, and 608 
were still under the thyroid treat¬ 
ment at the close of 1908. The re¬ 
sults are tabulated under various 
headings, special attention being paid 
to the increase in height as the most 
certain index of the benefit derived. 
Other findings are more liable to be 
influenced by subjective impressions. 
The report states that the results 
have been extremely satisfactory, 
confirming the efficacy of thyroid 
treatment as a prophylactic measure, 
especially in endemic foci of cretin¬ 
ism. In 677 cases followed to date 
marked improvement was obtained in 
48.6 per cent., and only 8.6 per cent, 
showed no benefit from the course. 
The most striking proof of the bene¬ 
ficial influence of thyroid treatment 
on the growth is the fact that in 377, 
that is, 85.7 per cent, of all cases, the 
former dwarf cretin children grew to 
be taller than the normal standard 
for their age. As a rule, treatment 


was restricted to school children: 
the oldest cretin was 26 years old. 
Even after 20 a number of the cretins 
grew much taller and the other symp¬ 
toms of cretinism became attenuated. 
This growth at this age is so sur¬ 
prising that it seems as if the grow¬ 
ing power of the preceding years 
had been held in reserve, until suddenly 
released by the thyroid treatment, when 
it made all its force felt in a relatively 
short period. A large number of the 
more interesting cases are cited in de¬ 
tail. One cretin, 20 years old, grew 11 
cm., but then refused to continue treat¬ 
ment, as he outgrew his clothes too 
fast. He did not lose his milk teeth 
until after thyroid treatment was 
commenced, although those of the 
second dentition were in place. A. 
von Kutschera (Wiener klin. Woch., 
June 3, 1909; Jour. Amer. Med. As¬ 
soc., July 17, 1909). 

Case of cretinism in a child of 4 
years which looked still like a 10 
months’ babe. No traces of the thy¬ 
roid could be discovered on palpa¬ 
tion. Thyroid treatment was then 
commenced, in 3 months the child 
had grown 10 cm. in height, and has 
developed normally since, and is now 
lively and healthy. C. Doderlein 
(Norsk Mag. f. Laegevidenskaben, 
July, 1910). 

The writer observed a case of com¬ 
plete cretinism in which normal men¬ 
tality recurred in a girl 5^2 years of 
age, who had first come under his 
observation when she was 3^2 months 
old. At that time she had all the 
typical characteristics of cretinism. 
Her extremities were the shortest he 
had ever seen. Her head was cov¬ 
ered with a thick mass of coarse, 
flaxen hair, her nose showed no de¬ 
velopment, her tongue protruded, her 
skin was dry, and her flesh showed 
no resiliency. She showed no anima¬ 
tion, even hunger apparently forming 
no part of her desires. At the pres¬ 
ent time she stood 40 inches in her 
shoes and she weighed 43 pounds 5 
weeks ago, which was more than the 
normal weight and height of the 
average child of her age. There was 


ANIMAL EXTRACTS (SAJOUS). 


711 


apparently nothing abnormal in the 
condition of the child at the present 
time; she played and talked just as 
any other child. The absence of the 
thyroid could not be attributed to 


been given twice daily. This amount 
was gradually increased until for a 
time, when she was about 4 years of 
age, she took 5 grains (0.3 Gm.) 
daily. Under this amount she de- 



Thyroid extract in cretinism. Cretinic idiot. 7 years old when thyroid treatment was begmn. 
Had ceased to develop when 3 years old. Changes after one year’s treatment. Growth 6% inches. 
(J. B. McGee: Cleveland Medical Gazette, December, 1900.) 


trauma, since there was nothing ab¬ 
normal at the time of birth except 
that the labor was rather precipitate. 
Thyroid medication was begun at the 
time he first saw the child, J4 grain 
(0.016 c.c.) of thyroid extract having 


veloped the typical signs of excess of 
thyroid. For some months she had 
been getting 3 grains (0.2 Gm.) 
daily. Very soon after beginning the 
thyroid treatment her hair came out 
in great masses and her skin came off 








712 


ANIMAL EXTRACTS (SAJOUS). 


in sheets, 2 or 3 inches coming off 
in 1 piece, and the child was practic¬ 
ally made over in a few weeks. The 
writer thought she was worth while 
presenting as demonstrating the re¬ 
sult of thyroid medication together 
with persistent and careful attention 
on the part of the mother. The case 
showed that if one took a case 100 
per cent, cretin early and adminis¬ 
tered the amount of thyroid that 
nature intended the child to have, one 
could get a perfect recovery, pro¬ 
vided the child had no other defect 
in any! other ductless gland secretion. 
W. B. Hoag (Med. Rec., Apr. 22, 
1916). 

To obtain such results, however, it 
is important to distinguish true cretins 
from idiotic dwarfs in whom thyroid 
is less beneficial or of no benefit what¬ 
ever. These are the mongol or kal- 
muek idiots and the micromelic or 
achondroplasic dwarfs. 

A comparison of the metabolic ac¬ 
tivity between a cretin over years 
old and 2 normal infants 8^ and 10 
months old, showed that it was 25 
per cent, lower in the cretin than in 
the 2 infants. Talbot (Amer. Jour. 
Dis. of Child., vol. xii, p. 145, 1916). 

In mongoloid mixo-idiocy the me¬ 
tabolism is irregular as regards the 
relations between the various ele¬ 
ments of the urine (increased elimi¬ 
nation of amino-acids). Under thy¬ 
roid treatment, though, the metab¬ 
olism improved, showing better oxi¬ 
dation by diminished elimination of 
amino-acids and giving normal amount 
of residual nitrogen and of uric acid. 
G. Caronia (La Pediatria, 26, 336, 
1918). 

Mongol or kalmuck idiots resemble 
cretins in many particulars. The 
mouth is kept open by the protruding 
and thickened tongue; the hair is dry, 
scarce, and coarse; the palatal arches 
are narrow, the development of the 
teeth is delayed, constipation is the 
rule, umbilical hernia is frequent, etc. 


But their skin is less rough, and the 
general development is less retarded, 
though that of the brain, judging from 
the degree of idiocy, must difier but 
little from that of a cretin’s. In this 
class of idiots the palpebral fissures are 
narrow and slope upward from the 
nose; the epicanthus proje.cts markedly 
over the inner canthus, as is the case 
in most Chinese. Nystagmus, i.e., os¬ 
cillatory movements of the eyeballs, is 
also common. Thyroid treatment 
though much less beneficial than in 
cretins, is, nevertheless, productive of 
good. The mental torpor is somewhat 
improved, the constipation and hernia 
are counteracted, and all functions 
seem to be activated. 

Achondroplasic dwarfs are in reality 
but cases of fetal rickets, are normal 
as to intelligence, but their face is that 
of the cretin, the skin, especially about 
the hands, also recalling that of the lat¬ 
ter. Other physical abnormalities are 
abnormal shortness and deformity of 
the limbs, marked narrowing of the 
palatal arch, and delay in the closure of 
the fontanelles. This condition, essen¬ 
tially due to morbid development of 
the bones and cartilages, is in no way 
influenced favorably by the use of thy¬ 
roid preparations. 

The dose should, of course, vary 
with the age of the patient from 
grain (0.015 Gm.) by the mouth in a 
1-year-old child to 3 grains (0.2 Gm.) 
in the adults. As tolerance varies, 
especially in children, small doses 
should be used at the start and very 
gradually increased until not more 
than 1grains (0.1 Gm.) of desiccated 
thyroid in a child and 9 grains (0.6 
Gm.) in an adult are given in divided 
doses daily. There is no. condition in 
which the prevailing empirical method 
of administering remedies should be 


ANTMAL EXTRACTS (SAJOUS). 


713 


more rigidly guarded against than in 
this, since excessive doses of thyroid 
not only inhibit its beneficial efifects by 
exciting violent catabolism, thus break¬ 
ing down the tissues instead of build¬ 
ing them up gradually, but they may, by 
doing so, cause death. 

[What unfavorable results have been re¬ 
corded can usually be ascribed to excessive 
doses. A certain critical author remarks, for 
instance, referring to personal experience of 
this sort: “There was no longitudinal 
growth of the bones nor any poisoning to 
be observed, but great bodily prostration 
and an augmentation of mental apathy, to¬ 
gether with emaciation dependent upon a 
loss of fat. From these unfavorable re¬ 
sults of therapy it is seen that the view is 
untenable that athyreosis is the cause of 
cretinism. These observations are the re¬ 
verse of the favorable ones made on the 
treatment of myxedema by thyroid gland, 
both in the young and in adults.” The 
great bodily prostration, emaciation, in¬ 
crease of apathy, etc., speak for them¬ 
selves. They had been caused by the ex¬ 
cessive doses the critic had administered. 
C. E. DE M. S.] 

The doses in which thyroid extract 
is usually prescribed are many times 
too large. The ordinary dose is 
officially quoted as from 3 to 10 
grains. There are very few people, 
except certain types of lunatics, who 
will tolerate such doses under any 
circumstances, and not even they are 
able to do so unless this dose is 
arrived at by a gradual increase from 
small beginnings. It is a clinical fact, 
well recognized by those who have 
any real experience in the use of the 
drug, that, the more the patient re¬ 
quires thyroid extract, the smaller 
should be the initial dose. Since the 
writer has been using it he has been 
driven back and back in his doses 
He now seldom begins with more 
than grain three times a day. He 
never prescribes a larger dose than 
5 grains thrice daily, and then only 
in pronounced myxedema after sev¬ 
eral weeks’ treatment. He has had 
many patients who were unable to 


take more than yjo grain once a day, 
but this was in each case quite suffi¬ 
cient completely to protect them from 
the symptoms of which they origi¬ 
nally complained. In connection with 
the allotrophic disease, he suggests 
that the prophylactic dose for an 
adult should not exceed Ho grain 
three times daily, and that grain 
three times daily is quite a sufficient 
therapeutic dose to start with. Leon¬ 
ard Williams (Practitioner, Nov., 
1911). 

The writer summarizes his results 
in 41 cases of sporadic cretinism in 
respect to physical development, men¬ 
tal development, retardation of mental 
and physical development, and the age 
at which treatment was begun, and of¬ 
fers the following conclusions: (1) 
Under thyroid treatment, if begun early 
the physical development may reach 
normal. (2) When treatment is begun 
late the physical as well as the men¬ 
tal development may remain much be¬ 
low normal. (3) The improvement 
in the mental development is never as 
great as in the physical. (4) The 
earlier the treatment is begun the 
better the results as far as mental de¬ 
velopment is concerned. (5) In con¬ 
genital cases, if the treatment is be¬ 
gun after the first year, marked intel¬ 
lectual retardation persists. The later 
the treatment is begun the more 
marked will be the retardation. (6) 
To obtain good results the treatment 
must be regular and continuous. A 
case presented well illustrates this 
point. While the treatment was regu¬ 
lar the increase in height was 3^ 
inches in a year, whereas during the 
periods when it was irregular it was 
as low as ^ inch in a year. (7) In 
the acquired as against the congeni¬ 
tal form, the intellectual development 
is less retarded than the physical de¬ 
velopment. C. Herman (N. Y. State 
Jour, of Med. Aug., 1914). 

The danger signals are those of hy¬ 
perthyroidism, previously described, 
the principal of which are an increase 
of temperature beyond normal, tachy¬ 
cardia, digestive disturbances, dyspnea, 


/14 


ANIMAL extracts (SAJOUS). 


and tremor* When any of these phe¬ 
nomena appear, the dose should be 
reduced until the temperature becomes 
normal—which may be one or two de¬ 
grees F. above the hypothermia usually 
observed in these cases. It should be 
remembered, however, that excessive 
doses may also cause hypothermia by 
inducing collapse. If the morbid ef¬ 
fects continue, the use of the remedy 
should be stopped a few days and then 
resumed with a smaller dose. Should 
the hyperthyroidism persist notwith¬ 
standing, Fowler’s solution in small 
doses soon arrests it. A common un¬ 
toward effect is bending of the bones 
of the legs, owing to softening of the 
bones. The child should not be al¬ 
lowed to go about too much, or when 
bowing of the legs appears it should 
be placed in bed, as advised by Telford 
Smith. 

Case of tetany following an acci¬ 
dental overdose of thyroid extract in 
a girl aged 3 years who presented 
stigmata of cretinism. 

The treatment was suspended for a 
fortnight and the symptoms gradually 
disappeared. Then grain of thy¬ 
roid extract was given t. i. d., in¬ 
creased to Vs grain. During the week 
after resuming the drug the “ac¬ 
coucheur hand” was again noticed. 
The dose was again reduced, but later 
increased. One month later a slight 
recurrence of the “accoucheur hand” 
compelled reduction of the dose of 
thyroid. Subsequently, though, on 
continuous treatment no recurrence 
of the tetany has been observed. G. 
W. R. Skene (Med. Review; Antisep¬ 
tic, May, 1911). 

[In the above case the toxic dose of thy¬ 
roid produced excessive catabolism and an 
accumulation of waste products in the 
blood. Hence, the tetany which is also 
produced when deficiency of thyroid also 
leads to accumulation of spasmogenic 
wastes because the latter are not submitted 
rapidly enough to hydrolysis, a process 


for which the thyroid secretion prepares 
the wastes by sensitizing them. C. E. 
DE M. S.] 

An important feature of the thyroid 
treatment of cretinism is the necessity 
in practically all cases of continuing it 
to prevent recurrence. The only per¬ 
manent benefit when thyroid is discon¬ 
tinued is the skeletal growth, though 
the original morbid phenomena never 
return with the same intensity. 

In an idiotic child, Payr, director of 
the Leipsic Surgical Clinic, implanted 
a part of a normal thyroid gland in 
the kidney. Mental regeneration is 
said to have immediately started and 
within r month the child was dis¬ 
missed from the hospital with the im¬ 
planted thyroid gland maintaining its 
functional capacity in the new body. 
Payr (Post-Graduate, June, 1912). 

In several cretins in whom cessa¬ 
tion of thyroid feeding led rapidly to 
a recurrence of myxedema the writers 
were led to try practical autotrans¬ 
plantation of the thyroid into the thy¬ 
roid capsule with success in all cases. 
There should be a minimum disturb¬ 
ance of the blood supply in the region 
in v’hich the transplant is placed, and 
foreign bodies, such as suture ma¬ 
terial, should not come into contact 
with the transplant. The varying de¬ 
gree to which a homotransplant takes 
depends on the amount of reaction 
between the host and the tissue trans¬ 
planted. A familial relationship and 
probably the early age of the animals 
on which operation was performed 
were shown to be important features 
of success. Hess and Strauss (Arch, 
of Internal Med., Apr., 1917). 

Several cretins occasionally occur in 
the same family, from the same 
mother, long intervals between births 
indicating the permanence of the patho¬ 
genic influence in the parent. Herman 
H. Sanderson (Jour, of the Mich. State 
Med. Soc., April, 1906), for example, 
observed 3 cases in one family, the 
patients being 21, 11, and 8 years of 


ANIMAL EXTRACTS (SAJOUS). 


715 


age, respectively. This points to the 
need of administering thyroid to the 
mother after the birth of a cretin, and 
during any subsequent pregnancy. 

Occasionally a case is met in which 
instability of the gland may manifest 
by deficient activity at one time and 
abnormal activity at another. 

Case of a diminutive woman aged 
33, who exhibited alternately, and at 
times even in conjunction, pro¬ 
nounced symptoms of hypothyroidia 
and hyperthyroidia. At night the pa¬ 
tient passed into a condition verging 
on myxedema, while in the post men¬ 
strual period her condition suggested 
Graves’s disease. Intervening be¬ 
tween the hypothyroidia and hyper¬ 
thyroidia were normal periods, the 
latter amounting, however, only to a 
few days in each month. It is as¬ 
cribed to variations in the circulation 
through the thyroid, inducing alter¬ 
nate states of inertia and overactiv¬ 
ity in its function. Leopold-Levi 
(Presse med., June 10, 1918). 

Myxedema. —Thyroid preparations 
are no less efficacious in this disease, 
which typifies hypothyroidism, in the 
adult than in cretinism, of which, in 
fact, this disorder is the prototype in 
adults. Here, again, we obtain those 
striking changes which clearly indicate 
that the remedy replaces in the organ¬ 
ism a constituent necessary to the vital 
process itself, and the least deficiency 
of which impairs all functions. This is 
further shown by the necessity of ad¬ 
ministering it continuously, year in and 
year out, as in cretinism, to prevent re¬ 
currence. 

Under the influence of thyroid prep¬ 
arations the morbid symptoms disap¬ 
pear. The dense, swollen tissues rap¬ 
idly recede, causing loss of weight; the 
projecting abdomen resumes its nor¬ 
mal contour; the skin loses its rough¬ 
ness and dryness; the hair grows more 
or less abundantly; the face loses its 


coarse and expressionless appearance, 
the wax-yellow color of the skin being 
replaced by a normal hue; the cyanosis 
of the lips, ears, and nose disappears. 
Even the slow and monotonous speech 
and mental torpor are promptly done 
away with, and if the case happens in 
an adolescent stunted by the disease 
growth is resumed and progresses rap¬ 
idly, as in cretinism. The physiolog¬ 
ical action is precisely that defined un¬ 
der the preceding heading, since we 
again meet with a rise of temperature 
and all the phenomena that denote in¬ 
creased metabolic activity, including a 
marked increase in the urea excretion. 
Menstruation, frequently suspended, 
soon returns. The appetite markedly 
increases, and the patient experiences 
a feeling of well-being 

The writer reviewed the history of 
the first case of myxedema success¬ 
fully treated by thyroid extract. The 
results obtained not only afforded 
definite proof that the thyroid gland 
produced an internal secretion, but 
showed that the thyroid insufficiency 
of myxedema in man could be made 
good by maintaining an adequate 
supply of thyroidal hormones from 
an external source. This patient, a 
woman of 46 when the treatment was 
begun, in 1891, lived until early in 
1919, when she died at the age of 74. 
By the regular and continued use of 
thyroid extract she was enabled to 
live in good health for over 28 years 
after she had reached an advanced 
stage of myxedema. During this 
period she consumed over 9 quarts 
of liquid thyroid extract or its equiv¬ 
alent, prepared from the thyroid 
glands of more than 870 sheep. 
George R. Murray (Brit. Med. Jour., 
Mar. 13, 1920). 

Myxedema is insidious in its 
course; this renders an early diag¬ 
nosis difficult. The importance of 
recognizing this disease lies in the 
fact that a sovereign remedy for it 
exists and that, unrecognized and 


716 


ANIMAL EXTRACTS (SAJOUS). 


long overlooked, such cases suffer 
serious physical and mental develop¬ 
ments. J. M. Anders (Trans. Amer. 
Climatol. Assoc.; N. Y. Med. Jour., 
Dec. 7, 1921). 

The dose generally employed in this 
disease is, as a rule, too large; 1 grain 
(0.065 Gm.) of desiccated extract 
daily, gradually increased until 2 grains 
(0.12 Gm.) are given t.i.d. Even smaller 
doses have given favorable results. 

Inasmuch as myxedematous patients 
are, as a rule, more susceptible to thy¬ 
roid preparations than normal subjects, 
it is always best to begin with small 
doses, since the degree of activity of 
the patient’s own thyroid, though 
greatly reduced, is an unknown quan¬ 
tity. The presence of unexpected ac¬ 
tivity is the main underlying cause of 
the so-called “susceptibility” often met 
with, a very small dose of the desic¬ 
cated thyroid sufficing in such patients 
to raise the standard of thyroid activity 
to its normal level. Again, as I have 
shown elsewhere (see “Internal Secre¬ 
tions,” 1st ed., p. 1139, 1907), there is 
a true cumulative action of the thyroid 
secretion (thyroiodase) when thyroid 
preparations are administered, and 
there comes a time when toxic phe¬ 
nomena appear, even under the influ¬ 
ence of very small doses. The tem¬ 
perature is the best guide. As it is be¬ 
low normal in all cases, the doses 
should be regulated in such a manner 
as to raise it to normal, reducing them 
as 98.6° F. (37° C.) is exceeded. The 
quantity required—usually somewhat 
larger in winter than in summer—by 
each patient may thus be readily de¬ 
termined while avoiding cumulative 
effects. 

In some cases it is well to ascertain 
whether a low blood-pressure is not 
perpetuating the peripheral hypother¬ 
mia by causing the blood to recede to 


the deeper great trunks. This may be 
done by giving strychnine simulta¬ 
neously in doses of %o grain (0.0016 
Gm.) three times daily. By stimulating 
the vasomotor center, it causes the ves¬ 
sels to contract, and thus to project the 
circulating arterial blood into the pe¬ 
ripheral capillaries. Strychnine, more¬ 
over, as shown by I. N. Love, tends to 
prevent the untoward effects of thyroid 
preparations. 

An important feature of the thyroid 
treatment of myxedema .is that the pa¬ 
tients should be kept in bed the first 
few weeks and not allowed to get up 
suddenly, to avoid sudden syncope—the 
cause of death in several cases on rec¬ 
ord. This precaution is especially nec¬ 
essary in aged and weak patients and 
quite as much where the improvement 
is rapid as in less favorable cases. As 
emphasized by Combe, Seymour Tay¬ 
lor, and others, alcohol should not be 
used during the treatment. 

Bourneville, Lancereaux, and other 
clinicians have called attention to the 
fact that symptoms of myxedema do 
not appear in infants until they are 
weaned. This is because the mother 
supplies her suckling what thyroid se¬ 
cretion it needs to satisfy the needs of 
its cellular metabolism. Thyroid ad¬ 
ministered to a nursing mother is also 
transferred to the nursling in such a 
degree, in fact, that the latter may pre¬ 
sent toxic phenomena. This suggests 
additional caution when the remedy is 
used in myxedematous women during 
pregnancy and lactation. 

Thyroid feeding was found by the 
writers to increase the catalase of the 
blood while decreasing it in the heart 
and probably in the fat and skeletal 
muscles. The increased blood-cata¬ 
lase may account for the increased 
oxidation in animals given thyroid. 
Burge, Kennedy, and Neill (Amer. 
Jour, of Physiol., June, 1917). 


ANIMAL EXTRACTS (SAJOUS). 


717 


Contraindications .—When any ady¬ 
namic cardiac disorder is present, the 
initial dose should be very small and 
very gradually increased, giving digi¬ 
talis simultaneously if indicated by the 
cardiac trouble. When angina pec¬ 
toris accompanies myxedema, small 
doses of thyroid are beneficial, espe¬ 
cially if the patient is placed on a vege¬ 
table diet. 




beneficial effects of the thyroid prep¬ 
aration. 

The danger signals when thyroid is 
used in myxedema are, as in cretin¬ 
ism : tachycardia, palpitations, prostra¬ 
tion with sweating, rapid emaciation, 
gastrointestinal disorders, anemia, head¬ 
ache, and in some cases excitement 
recalling hysteria. When the doses 
(even though small) are too large for 



Fig. 1.—True myxedema. (Ilertoghe: Bul¬ 
letin de I’Academie Royale de Medecine de 
Belgique.) 

Occasionally aged subjects fail to 
respond to the thyroid treatment alone, 
and the disease progresses until mental 
aberration, melancholia, or even mani¬ 
acal disorders supervene. The de¬ 
pressed forms of mental disorder are 
probably due to the low blood-pressure 
which characterizes the disease, and 
which the thyroid tends to increase. 
Strychnine counteracts this untoward 
action, however, while enhancing the 


Pig. 2.—The same patient after thyroid 
treatment. (Hertoghe: Bulletin de I’Acade¬ 
mie Royale de M6decine de Belgique.) 

the patient, urticaria may appear. This 
is due to cutaneous irritation caused by 
the more or less toxic wastes produced 
in excess owing to the excessive catab¬ 
olism induced, and which the kidneys 
cannot eliminate with sufficient rapid¬ 
ity. Cessation of the drug for a few 
days usually causes all these morbid 
effects to disappear, after which the 
remedy may be resumed in very small 
doses. 








718 


yXNIMAL EXTRACTS (SAJOUS). 


After recovery, the patient’s health 
can usually be maintained, i.e., recur¬ 
rence of the disease prevented, by ad¬ 
ministering small doses, 1 grain (0.065 
Gm.) daily or every other day—just 
enough to sustain the temperature up to 
normal. In winter it is sometimes nec¬ 
essary to increase the dose somewhat 
to obtain this result. The prolonged 



Fig. 3.—True myxedema; sister of patient 
in Figs. 1 and 2. {Hertoghe: Bulletin de 
I’Academie Royale de M^decine de Belgique.) 


use of the remedy does not, with rare 
exceptions, diminish the need of it to 
ward off the disease; cessation after 
several year’s use will be followed by 
prompt recurrence of the morbid phe¬ 
nomena. 

Case in a man of 36 years in which, 
after recovery from the initial treat¬ 
ment by the thyroid extract (which 
lasted two months in continuous dos¬ 
age), the patient was never under 
treatment longer than four weeks at 
one time. The longest respite from 
thyroid therapy was for a period ex¬ 


tending from May, 1907, to October 
of the same year, a period of five 
months; at the end of this time some 
of the old symptoms were again in 
evidence, namely, characteristic color, 
loss of expression, swelling and puffi¬ 
ness under the eyes; the mentality, 
however, continued good. The pa¬ 
tient himself wanted to be placed 
under treatment again. An interest¬ 
ing feature of the case, aside from its 
rarity in these parts, is that if the pa¬ 
tient takes more than three tablets a 
day, now that a cure is established, or 
continues the treatment for more 
than three weeks, he soon shows the 
symptoms of exophthalmic goiter, 
namely, nervousness, sleeplessness, 
slight exophthalmos, nausea, some¬ 
times vomiting and general weakness. 
S. E. Simmons (Jour. Amer. Med. 
Assoc., May 15, 1909). 

Occasionally a case is met with in 
which the thyroid treatment is followed 
by permanent recovery. Such cases are 
probably instances of temporary myxe¬ 
dema due to obstruction of the lym¬ 
phatics through which the secretion 
gains access to the general circulation, 
or to some other factor interfering 
temporarily with the functions of the 
gland. 

Between the cases in which contin¬ 
uous after-treatment is required and 
those that proceed to recovery are 
some in which respites of several weeks 
in the after-treatment are required to 
obtain the best results. This is a re¬ 
sult obtained, however, only when large 
doses of thyroid are used in the after- 
treatment. There is danger in such 
cases of causing hyperthyroidism, i.e., 
the symptoms of exophthalmic goiter, 
and it is preferable to reduce the dose 
until the exact quantity required con¬ 
tinuously to keep the patient well is 
ascertained. 

Thyroid grafting has been performed 
successfully in animals, especially by 



ANIMAL EXTRACTS (SAJOUS). 


719 


Christiani, and more recently in human 
subjects suffering from myxedema or 
cretinism. In the earlier operations, 
the improvement lasted only as long as 
the secretion that happened to be in 
the implanted tissues lasted, but in re¬ 
cent years better results have been ob¬ 
tained, the grafted fragments of thy¬ 
roid assuming physiological functions 
to a sufficient degree to prevent recur¬ 
rence of the disease. 

Case of a young woman who, be¬ 
coming tired of the preventive treat¬ 
ment by thyroid, requested a substi¬ 
tute. The writers inserted portions 
of a sheep’s thyroid gland in a series 
of grafts under her skin on two occa¬ 
sions three and a half months apart. 
The thyroid feeding was gradually 
diminished until it was reduced to a 
few drops a day of a liquid extract. 
About six months after the second 
transplantation the patient was de¬ 
livered at term of a well-developed 
healthy infant. It was observed that 
during the latter months of her preg¬ 
nancy the grafts became enlarged, 
evidently from congestion, being af¬ 
fected like the normal thyroid by the 
pregnancy. The successful termina¬ 
tion of the pregnancy was ascribed in 
great part to the thyroid treatment, 
and especially the implantation of the 
functionally active thyroid under the 
skin. Lannelongue, in a case of a 
myxedematous infant, had previously 
implanted the first fragment of a 
sheep’s thyroid in the human subject. 
The child’s condition appeared im¬ 
proved, and the development ^of the 
disease became a little less active. 
Charrin and Christiani (Le Bull, 
medicale, July 11, 1906). 

The best results can certainly be ob¬ 
tained with repeated implantation of 
small scraps, and for this it is better to 
implant the scraps in the subcutaneous 
tissue (Christiani) or in the peritoneal 
tissue (von Eiselsberg). 

Series of personal experiments in 
thyroid implantation showed that thy¬ 


roid tissue of the guinea-pig trans¬ 
planted in the same animal heals most 
easily and best /hen the transplanta¬ 
tion is made into the subcutaneous 
connective tissue; likewise, the peri¬ 
toneal cavity shows itself a very 
favorable implantation site; that 
transplantations into the spleen heal 
fairly well, but the end results are less 
good and not so certain as those ob¬ 
tained when one uses as implantation 
sites the two places above named; the 
liver and the bone-marrow are very 
unfavorable organs for the healing in 
the thyroid tissue; that thyroid trans¬ 
plantation promises in general more 
fruitful results if one avoids all bleed¬ 
ing in the pocket destined to receive 
the graft; that if one transplants the 
thyroid tissue in conjunction with 
the connective-tissue capsule pertain¬ 
ing to it, it is to be observed that the 
follicles in the vicinity of this capsule 
are better preserved and more numer¬ 
ous than the more remote follicles; 
that the best results are attained if 
one transplants into the subcutaneous 
tissue very thin slices of thyroid tis¬ 
sue instead of larger pieces; one con¬ 
dition is that one of the surfaces of 
the implanted piece is covered by the 
connective-tissue capsule of the thy¬ 
roid. Carraro (Deut. Zeit. f. Chir., 
Feb., 1909). 

The more recent work of Payr 
(1912) and of Hess and Strauss (1917) 
has been reviewed under the preceding 
heading. 

Obesity. —The treatment of this 
condition by means of thyroid prep¬ 
arations was far more in vogue a few 
years ago than at present, owing mainly 
to its indiscriminate use by laymen, and 
to the use of excessive doses by the 
profession. P)Oth these features were 
the cause of dangerous phenomena 
(and sometimes death) during the 
course of treatment, or of pernicious 
after-affects. When thyroid prepara¬ 
tions are used intelligently, however, 
adjusting the dose to the needs of each 


720 


ANIMAL EXTRACTS (SAJOUS). 


case, and regulating judiciously the 
concomitant diet—which in some cases 
means an ' increase—a great deal of 
good may be done in the great major¬ 
ity of cases, besides improving the ap¬ 
pearance of the patient and his general 
well-being. (See article on Obesity, 
in the seventh volume.) 

The cases in which thyroid prepara¬ 
tions act favorably are those in which 
metabolic activity, especially its cata¬ 
bolic phase, is deficient. The fat, ruddy 
boy or the plethoric, vigorous, red¬ 
faced high-liver do not belong to this 
category. Those that do are pale, 
flabby, anemic, in most instances fe¬ 
males between 25 and 45 in which the 
heart beat is weak, sometimes irregular 
and rapid with compressible pulse. 
The fat in such is more or less irreg- 
ulajly distributed in the subcutaneous 
tissues; they suffer from dyspnea, es¬ 
pecially on exertion, and fall asleep 
readily at any time. Such cases are in 
reality instances of mild myxedema in 
which the thyroid does not supply quite 
enough secretion to satisfy the needs 
of the organism. It is not a question 
of overeating with them; such patients, 
in fact, are, as a rule, abstemious, the 
slowness of their tissue exchanges 
causing them to have but little appetite. 
Unable to burn up their carbohydrates, 
sugars, starches, and fats as fast as 
they are ingested, fat steadily accumu¬ 
lates in all tissues. 

Thyroid preparations, when judi¬ 
ciously used under such circumstances, 
are of value mainly because the role of 
thyroid secretion they replace is pre¬ 
cisely—from my viewpoint—to en¬ 
hance the catabolic phase of metab¬ 
olism, essentially the function at fault 
in obesity. The fat-cell is rendered 
more susceptible to oxidation—along 


with the other tissues—and the excess 
of fat is steadily consumed. 

Series of about 100 cases of obesity 
in which thyroid extract was used. 
No untoward symptoms were noticed 
in any of the cases, malaise, head¬ 
ache, palpitation, and nervous de¬ 
rangement being entirely absent. Al¬ 
buminuria was not seen at any time. 
The thyroid gland used in all in¬ 
stances was B. W. & Co. tabloids. 
The initial dose was 214 grains with 
each meal, either mixed with the 
food or taken with a little water. 
After seven days the dose was in¬ 
creased to 5 grains with each meal, 
and this dose was not increased in 
any case. The tabloids were crushed 
before being taken. In the successful 
cases summarized below no alteration 
in diet was ordered, the patient eating 
and drinking anything he or she de¬ 
sired. Alcohol was, however, strictly 
prohibited in any form. 

Of 78 females treated 69 were be¬ 
tween 25 and 45; their average weekly 
loss was 234 to 4 pounds, and the re¬ 
sult was permanent cure; 9 were be¬ 
tween 15 and 19, and there was no 
permanent result in any of them. Of 
25 men 9 were between 30 and 47; 
they lost on an average 2 to 3l4 
pounds weekly; the cure was perma¬ 
nent; 11 men between 30 and 47 lost 
1 to I 34 pounds on an average, but 
the result was not permanent; on 5, 
between 14 and 17, there was no 
effect at all. W. J. Hoyten (Brit. 
Med. Jour., July 28, 1906). 

The writer emphasizes the neces- • 
sity for distinguishing between obe¬ 
sity due to overeating or laziness and 
obesity for which some constitu¬ 
tional cause is responsible, as treat¬ 
ment varies widely with the factors 
involved. In the exogenous type, 
overeating and lack of exercise may 
combine to induce the obesity; the- 
tendency to overeat and to refrain 
from exercise may be due to abnor¬ 
mal instincts, possibly the result of 
reflexes perverted from normal by 
some chemical influence. It is usu¬ 
ally possible in time to train these 


ANIMAL EXTRACTS (SAJOUS). 


721 


instincts into normal routes. Reason¬ 
ing, compulsion and psychic measures 
are usually necessary, in addition to 
diet and exercise, in these cases. 
The other type of obesity, the endog¬ 
enous, constitutional type, he regards 
as traceable to abnormal thyroid func¬ 
tioning. Congenital or acquired 
weakness or degeneration of the thy¬ 
roid may induce the obesity directly 
or the thyroid may become a factor 
in the obesity only secondarily, as in 
case of pancreas disease (demon¬ 
strated only experimentally as yet); 
disease in the ovaries or testicles 
(deficiency of the interstitial sub¬ 
stance); disease in the pituitary body 
(adiposo-genital dystrophy); disease 
in the pineal gland or thymus (both 
dubious). There may also be a com¬ 
bination of both the exogenous and 
endogenous type, especially in the young. 

Throughout the endogenous forms, 
abnormal thyroid functioning is com¬ 
mon to all, and treatment of consti¬ 
tutional obesity must be based on 
thyroid treatment. It is unquestion¬ 
able now that the reliance on thyroid 
treatment is increasing, the dread of 
it diminishing. 

The dangers from thyroid treat¬ 
ment are just as great as ever, but 
we know better how to watch out 
for them and guard against them. 

The writer adds that even in cases 
amenable to systematic dietetic meas¬ 
ures alone, the prolonged restriction 
of the diet seems to him more of 
an evil than a course of thyroid 
treatment. 

With this the diet need not be so 
strictly regulated and the effect of 
the thyroid treatment is often per¬ 
manent, so that the patients can eat 
like other people afterward without 
bringing back the obesity. 

During the thyroid course ample 
provision of albumin should be en¬ 
sured. The urine should be ex¬ 
amined often for sugar. 

The tendency to acceleration of 
the heart action and reduction in 
blood-pressure can be warded off by 
daily small doses of some digitalis 
preparation. • 


Thyroid treatment is not required in 
the exogenous type of obesity, diet 
and exercise answer the purpose, and 
without training in this line the obe¬ 
sity will return whether thyroid 
treatment has been taken or not. Ap¬ 
paratus to reduce obesity by electric 
contractions in the muscles are ridi¬ 
culed by the writer as unable to in¬ 
duce any appreciable effect on the 
oxidation processes beyond the effect 
of suggestion. In conclusion he 
urges physicians to keep up a con¬ 
stant warfare against the “patent 
medicines” advertised to cure various 
ills, and especially the obesity cures, 
as they are by no means harmless 
remedies. Von Noorden (Jour. Amer. 
Med. Assoc.; Therap. Monats., Jan., 
1915). 

The writers observed the case of a 
woman who had been thin until the 
age of 18, when she contracted syph¬ 
ilis; she then began to increase in 
weight, finally reaching 157 kg. (345 
lbs.), although only 1.6 meters (5 ft. 
3 in.) tall. 

The pituitary was found normal, 
but both thyroid and ovaries were 
pathologic. 

There were 7,756,200 erythrocytes 
to 11,320 leucocytes, with Arneth dis¬ 
placement to the left. 

There was very little fat around 
the heart, but the myocardium 
showed degeneration, and this was 
probably responsible for the sudden 
death. 

The histologic findings in the thy¬ 
mus showed functional persistence. 
Maranon and Bonilla (Revue Neurol., 
Sept., 1920). 

Contraindications to the use of thy¬ 
roid preparations in obesity have been 
elaborated by various observers; but 
perusal of their work indicates clearly 
that they have been administering ex¬ 
cessive doses. Such doses are always 
dangerous in the obese, since the heart 
is itself invariably fatty, while, con¬ 
versely, small doses are always help¬ 
ful because they very gradually rid 


722 


ANIMAL EXTRACTS (SAJOUS). 


the heart of the fat which compro¬ 
mises its functions and eventually 
causes death when the patient has not 
been carried off by some intercurrent 
disorder. Even moderate doses have 
not proven harmful when the patient 
was under medical surveillance. 

The dose of desiccated thyroid need 
not exceed 1 grain (0.65 Gm.) three 
times daily in any case. This suffices 
to cause a decrease of weight of from 
one to three pounds a week, and some¬ 
times more, Anders (“Practice,” 8th 
ed., p. 1276) having observed in 2 
cases under this dose “a progressive 
loss of weight at the rate of 4 to 6 
pounds per week, respectively, with¬ 
out injury to the general health.” 
Such doses do not impose upon the 
patient the need of modifying his 
usual mode of living, and his diet 
need not, unless excessive, be altered. 
When the obesity is accompanied by 
weakness, the appetite is usually in¬ 
creased, especially when, as is my 
custom, gr. %o (0.0012 Gm.) of 
strychnine is given with each dose 
of desiccated thyroid. The patient 
does best under these conditions 
when lean meats, plainly broiled, 
roasted, or stewed, constitute the in¬ 
crease of his dietary. This treatment 
is valuable in another direction: it 
tends to counteract any tendency to 
constipation that may be present. 

Danger signals or untoward effects 
are not met with when small doses 
are given, as previously stated, but 
the physician has occasionally to treat 
some victim of excessive dosage. 

A case was observed by Notthaft 
in which a man took for obesity 
nearly 1000 5-grain tablets of thyroid 
extract within five weeks. After the 
first three weeks he began rapidly to 
develop the symptoms of acute 


Graves’s disease. When thyroid was 
stopped and the patient was put upon 
arsenic all the symptoms disappeared 
quickly, excepting the eye changes 
and the goiter, which were still nota¬ 
ble for about six months. 

The untoward effects most fre¬ 
quently met with in obese subjects are 
of cardiac origin : marked discomfort 
in the precordia, dyspnea with tend¬ 
ency to heart-failure. In some in¬ 
stances this has been followed by death 
when marked fatty degeneration hap¬ 
pened to be present. But, as stated, 
these do not occur when small doses— 
1 grain (0.065 Gm.) of the desiccated 
thyroid—are used. Even the greatest 
watchfulness will not prevent toxic ef¬ 
fects when large doses are adminis¬ 
tered, since the accumulation of the 
thyroid principle proceeds at a rapid 
rate and the milder symptoms of thy- 
roidism are almost at once followed 
by its acute manifestations—^those pre¬ 
viously described. 

Miscellaneous Disorders.—In the 
foregoing diseases thyroid treatment 
may be regarded as a specific, none 
other affording satisfactory results. Its 
use is being extolled in many other dis¬ 
orders ; but it is still a question whether 
it procures better effects or even as 
good results as other available rem¬ 
edies. These will be considered in 
their alphabetical order. 

Acromegaly.—The reports of cases 
of this disease treated with thyroid 
have been insufficient to warrant a con¬ 
clusion, the results having been contra¬ 
dictory. This is probably due to their 
empirical use. According to my inter¬ 
pretation of the disease ; hypertrophy 
of the pituitary causes excessive activ¬ 
ity of the adrenals and thyroid (which 
the pituitary governs) for a time, i.e., 
during the sthenic period of the disease. 


ANIMAL EXTRACTS (SAJOUS). 


723 


Given during this period, thyroid prep¬ 
arations can only, therefore, add fuel 
to the fire and do harm. There comes 
a time, however, usually after several 
years, when the enlargement of the pit¬ 
uitary ceases and degeneration of this 
organ occurs, initiating the asthenic 
period. 

The adrenals and thyroid then 
usually reduce their functional ac¬ 
tivity inordinately, and oxidation and 
metabolism are inadequate for the per¬ 
petuation of the vital functions. Here 
thyroid (preferably with adrenal) is 
useful and may serve greatly to pro¬ 
long life. 

Instances of benefit in advanced cases 
have been published by various authors. 
Thus, Sears observed a case treated 
with dried thyroid gland in gradually 
increasing doses until 12 grains a day 
were taken, besides galvanism and 
tonics. Three months later she was 
feeling very much better, her memory 
had improved, and she spoke and 
moved more rapidly. She had lost 
over 20 pounds in weight, but felt 
stronger. The history of the case and 
the marked physical changes leave little 
doubt that it was a case of acromegaly, 
but certain anomalous symptoms—such 
as the puffy conditions of the eyelids, 
which may, however, have been simply 
the result of anemia, though its appear¬ 
ance was somewhat different; the slow 
speech, and the altered mental state— 
suggested that her condition was also 
associated with a loss of function of 
the thyroid gland. 

Rolleston also refers to a woman 26 
years old who had suffered from acro¬ 
megaly for upward of two years, and 
who for a period of five months had 
been treated with mixed pituitary and 
thyroid extracts, with great improve¬ 
ment. At the present writing (1921), 


however, the whole subject is being 
considered from another viewpoint 
which is reviewed at length in the 
article on Acromegaly in the present 
volume. 

Arteriosclerosis.—As is well known, 
the iodides are used with benefit in 
this condition. It naturally follows 
that thyroid preparations, which owe 
their therapeutic activity to the iodine 
in organic combination they contain, 
should likewise prove beneficial. This 



Case illustrating the association of acromegaly 
and goiter. (0.11. Murray.) 


proved true in cases reported by Lan- 
cereaux (La Semaine med., Jan. 4, 
1899), James Barr (Brit. Med. Jour., 
Jan. 20, 1906), and other authorities. 
The favorable action of thyroid in 
these cases, however, necessitates the 
use of large doses—5 grains (0.3 Gm.) 
three times a day—enough to cause 
general vasodilation. As such doses are 
unsafe in aged subjects, who constitute 
the greatest proportion of our cases, 
its use should be limited to middle-aged 
patients, therefore, reserving the io¬ 
dides for the former. Sir James Barr, 
in fact, prefers iodine to thyroid. 

Arthritis, Chronic Rheumatoid.— 
In this disease good results are occa- 


724 


ANIMAL EXTRACTS (SAJOUS). 


sionally obtained when no other agent 
will produce the least effect. Leopold- 
Levi and de Rothschild, for example, 
describe the phenomena observed in 
2 cases of chronic rheumatism with 
hydrarthrosis in which thyroid extract 
proved of distinct value. In 1 of 
these the hydrarthrosis followed a fall 
from a bicycle, and was the precursor 
of attacks of muscular rheumatism, all 
the joints being gradually involved in 
the. morbid process. Notwithstanding 
seasons at Aix-les-Bains, Dax, and 
other stations, the patient became quite 
impotent, having even to be fed. The 
usual remedies proved unavailing, 
though aspirin and iodine seemed, at 
least for a while, to be of some benefit. 
The patient’s condition becoming stead¬ 
ily worse, thyroid extract was tried, be¬ 
ginning with grains every other 
day during ten days, followed, after 
five days, by resumption of the rem¬ 
edy; then giving again only 1% grains 
every other day. This dose was grad¬ 
ually increased until, eleven months 
later, the patient was taking 7% grains, 
in divided doses, daily. Good results 
have also been recorded by Revilliod, 
Lancereaux, and others. 

The beneficial effects of the drug be¬ 
come self-evident when its action and 
the pathogenesis of chronic rheumatism 
are interpreted from, my standpoint. 
Briefly, while I have ascribed this dis¬ 
ease to ^‘inadequate catabolism of tissue 
wastes, and excitation, by the toxic 
products formed, of the vasomotor 
center” thyroid extract, as stated in the 
foregoing pages, enhances general oxi¬ 
dation and the destruction of wastes, 
by increasing the blood’s asset in op¬ 
sonin and autoantitoxin. 

Thus, incirease of appetite was the 
first effect noted in the cases referred 
to above; this is a normal result, since 


the greater cellular activity and catab¬ 
olism created a greater demand for 
foodstuffs. Increased heat production 
soon replaced the marked and constant 
chilliness from which the patient suf¬ 
fered—an effect due to the marked in¬ 
crease of oxidation the thyroid extract 
engendered throughout the body. The 
dose was increased to 1% grains one 
day, then to 3 grains the next, this being 
continued ten days. After a period of 
rest of five days, 3 grains were again 
given daily. The pain became less—a 
fact due to decrease of the vascular ten¬ 
sion, owing to increased destruction of 
the toxic wastes which, as I have 
pointed out elsewhere, excite the vaso¬ 
motor center, thus causing constriction 
of all arteries. The sensory nerve-ter¬ 
minals being relieved of the hyperemia 
which caused the pain, the latter be¬ 
came less marked in proportion. 
Closely connected with this beneficial 
action was the effect on the joints, viz.: 
the hydrarthrosis became reduced. Be¬ 
ing also due to excessive vascular ten¬ 
sion, it is plain that by causing vaso¬ 
dilation, in the manner just explained, 
thyroid extract caused the excess of 
fluid to leave the joints. The dose be¬ 
ing still further, increased until 7% 
grains were taken daily, emaciation 
occurred—a well-known effect due to 
excessive catabolism provoked by large 
doses of thyroid extract. 

Eleven months’ treatment brought 
Leopold-Levi and de Rothschild’s case 
back to a condition of comfort, the 
joints having resumed their shape and 
flexibility—with the exception of one 
knee, which remained ankylosed—ow¬ 
ing doubtless to fibrosis, a condition 
beyond the reach of the remedy. This 
does not militate against its use, how¬ 
ever; it simply shows that the treat¬ 
ment was resorted to too late to avoid 


ANIMAL EXTRACTS (SAJOUS). 


725 


irremediable organic lesions. The aU' 
thors, in fact, refer to a case treated 
by Parhon and Papinian (Presse med., 
No. 1, p. 3, 1905) in which thyroid 
extract had produced, though the dis¬ 
ease was of twenty-four years’ stand¬ 
ing, “a true regeneration.” When IY 2 . 
grains( in five divided doses) daily had 
been given some time, palpitations, 
tachycardia, and arrhythmia appeared. 
On withdrawing the remedy these un¬ 
toward effects ceased, but recurred as 
soon as its use was resumed. This 
affords additional evidence in support 
of a fact I have often emphasized, viz.: 
that the beneficial effects of thyroid 
extract are obtained only when small 
doses are used. 

Case of rheumatoid arthritis in 
which the writer was struck by the 
patient’s rough, dry, harsh skin, crisp 
hair, husky voice, and deep supra¬ 
sternal notch; the prominence of the 
trachea, and apparent absence of thy¬ 
roid gland, analogy to other condi¬ 
tions suggesting deficiency of thyroid 
secretion. 

Accordingly, the extract of thyroid 
was administered in doses of 5 grains 
three times daily, together with adju¬ 
vant treatment to be mentioned pres¬ 
ently. In a month the results 
were remarkable. The patient could 
struggle on crutches from one room 
to another, his appetite returned, and 
pain was almost gone. In three 
months he could walk with two 
sticks, and in eighteen months he was 
able to walk three miles with the aid 
of one stick. His elbows and should¬ 
ers have regained their mobility al¬ 
most entirely, and he has been for a 
year able to do without his thyroid 
extract without a relapse. At the 
present date he is able to get about 
well, with slight flexion of one knee 
and some metacarpophalangeal de¬ 
formity, but is fat and well. 

Two additional cases in which 
marked improvement occurred. In 
the writer’s opinion the group of 


cases likely to receive benefit are 
those in which'changes are chiefly 
confined to the synovial membranes, 
without erosion of cartilage or ebur- , 
nation of bone, such cases in fact as 
Schuller describes as “chronic villous 
arthritis.” Wilson (Brit. Med. Jour., 
Dec. 10, 1910). 

After prolonged observation the 
author is inclined to believe that very 
few cases of long-standing arthritis 
exist without some degree of thyroid 
failure. There can be little doubt 
that rheumatoid arthritis (including 
both osteoarthritis and chronic infec¬ 
tious arthritis) is the result of 
chronic toxemia following an original 
acute condition in the majority of 
instances. In the early stages some 
or all of the following symptoms may 
occur: Changes in skin pigmenta¬ 

tion; patches varying from a lemon 
color to brown; spots like bruises oc¬ 
curring spontaneously; occasionally 
white spots; vasomotor disturbances; 
perspiring hands and feet, or paroxys¬ 
mal perspirations of other restricted 
areas; rashes; local anemias or as¬ 
phyxia; shooting pains; muscular 
cramps; paresthesias; neuralgic head¬ 
aches; gradually increasing flatfoot; 
muscular weakness; morning stiff¬ 
ness, etc. These symptoms may pre¬ 
cede any noticeable arthritis. The 
poisons that are affecting the system 
as a whole may damage the thyroid, 
and, although at first there may be 
excessive secretion of this gland, 
sooner or later more or less failure 
occurs, and then is the time to be¬ 
gin giving thyroid extract. 

Care should be taken to distinguish 
between thyroid failure and failure of 
the pituitary body. The former is 
associated with a slow pulse, the lat¬ 
ter with a frequent pulse. In either 
case the patient may be puffy and 
lethargic. In simple obesity, on the 
other hand, patients are often bright 
mentally and active physically. 

As to the diet in rheumatoid arth¬ 
ritis, meat, speaking generally, should 
be eaten; but if the thyroid function 
is imperfect,-meat becomes danger¬ 
ous unless sparingly taken. 


726 


ANIMAL EXTRACTS (SAjOUS). 


It is best to give a small dose of 
thyroid at first. For some patients 
the author prescribes as little as V/z 
grains (0.1 Gm.) once daily. They 
lack resisting power and cannot with¬ 
stand the toxic effects of excessive 
doses. As a precaution it is well to 
allow a few days’ interval from time 
to time in any case. The pulse 
should be watched, and if blood- 
pressure records are not obtainable 
any undue fall should be noted by 
the trained finger. 

Thyroid treatment in chronic ar¬ 
thritis is, of course, merely an ad¬ 
junct, and cannot be depended upon 
alone to deal successfully with the 
disease. Septic foci should be looked 
for and dealt with, and the author be¬ 
lieves that in these cases all teeth 
should be removed, since few are 
healthy. 

Teeth may be responsible for much 
gastrointestinal catarrh even when 
there is no actual pyorrhea. 

In cases where thyroid failure has 
become thoroughly established, it is 
necessary for the patient to take thy¬ 
roid in suitable doses for the rest of . 
his life; W. J. Midelton (Pract., Jan., 
1912). 

The writer observed the case of a 
girl of 15 who had suffered 3 severe 
attacks of acute articular rheumatism, 
the last of which left a contracture 
of the tendons of both hands, render¬ 
ing them useless. Various anti-rheu¬ 
matic remedies and physical measures 
having proved ineffective 10 days, 
thyroid therapy, with no associate 
treatment whatever was substituted. 
After 6 days of treatment the bene¬ 
fit was apparent and at the end of 3 
weeks the normal conditions of the 
hands had been fully restored. R. G. 
Pizarro (Sem. medica, xxiii, 445, 
1916). 

The writer has cured a number of 
cases with thyroid alone, where signs 
of hypothyroidism and dermographia 
were present. Leopold-Levi has em¬ 
phasized the importance of ascertain¬ 
ing the presence of hypothyroid stig¬ 
mata. Blind (Paris Med., June 18, 
1921). 


When the salicylates fail in rheu¬ 
matism, the concomitant administra¬ 
tion of thyroid in small doses will 
cause the former to act. 

Cancer.—Thyroid preparations have 
been tried by a number of clinicians 
in this disease. Some have obtained 
favorable results; others observed only 
temporary benefit; others again have 
observed no effect whatever. There 
are many indications, however, that, 
in due time, will prove .thyroid to be a 
valuable agent in this condition. 

Report of several cases treated by 
the writer with no other agent than 
thyroid in which recovery has per- 
• sisted over 9 years, the cases treated 
including such forms as mammary 
and uterine cancer. Robert Bell 
(Trans. Brit. Gynec. Soc., vol. v, 
1896). 

In mammary cancer the use of thy¬ 
roid alone was sufficient to cause the 
entire disappearance of the growth. 
In this case the writers began the 
treatment by giving a daily dose of 3 
grains (0.2 Gm.) and increasing the 
dosage until the patient was taking 
15 grains (1 Gm.) a day. At the 
time of this reporting, 2 years there¬ 
after the patient was in perfect health 
and no trace of the cancerous growth 
could be found. Page and Bishop 
(Lancet, May 28, 1898). 

Thyroid gave better results in the 
treatment of cancer than any other 
agent. Dennis (Jour. Amer. Med. 
Assoc., Oct. 19, 1901). 

In a very severe case of cancer— 
the diagnosis and prognosis being 
confirmed by Sir Francis Taking—in 
which the termination was fast ap¬ 
proaching and the pain and suffering 
were intense, the writer obtained re¬ 
sults bordering on the supernatural. 
Convalescence began immediately, so 
that by the end of January—thyroid 
extract, 5 grains (0.3 Gm.) quickly 
increased to 20 grains (1.3 Gm.) 
daily, having been begun at the end 
of November—the patient was up 
and free from pain. In the following 


ANIMAL EXTRACTS (SAJOUS). 


727 


October—nearly a year afterward— 
she “was quite well and was follow¬ 
ing an active life.” H. A. Beaver 
(Brit. Med. Jour., Feb. 1, 1902). 

The writer tried experimentally 
during the past 25 years many drugs 
and many gland extracts, including 
all vaunted agents from mixed tox¬ 
ins to the last recommended gland 
extract, and with the exception of 
thyroid extract, and possibly arsenic, 
he has never seen any definite benefit 
from their use. A. R. Robinson (N. 
Y. Med. Jour., Dec. 29, 1906). 

Report of a case of multiple car¬ 
cinoma of the skin and subcutaneous 
tissue, in a widow aged 61. The 
original growth had been removed a 
year previously, but others since ap¬ 
peared, and the patient’s health was 
suffering severely. Thyroid was tried, 
starting with 5 grains, gradually in¬ 
creased to 15 grains daily. The pa¬ 
tient quickly showed improvement; 
palpitation, sickness, and emaciation 
gradually disappeared along with the 
growths themselves. In less than 
three months they had entirely gone. 
The patient was practically well and 
had recovered her lost weight of 3 
stone. This occurred in 1901. Ten 
years later, the patient was still well. 
E. Hughes Jones (Brit. Med. Jour., 
Feb. 25, 1911). 

The causes which led many clini¬ 
cians to shun thyroid were, first, too 
large dosage, and, second, unreliabil¬ 
ity as regards physiological action of 
the then prevailing preparations. 
Internists are found prescribing a 
daily dose of 3 to 6 grains (0.2 to 
0.4 Gm.), with beneficial and not un¬ 
toward results. Buford starts with 
Vj. to 3 grains (0.03 to 0.2 Gm.) of 
the desiccated thyroid every 12 hours, 
and gradually increases the dose, while 
Stern, Percy, Middleton, Leopold-Levi, 
Firth, Dupug, Valmorin, Variot, 
Minoret, Siegmund and many other 
observers, all are ardent advocates ot 
the minimum dose. 

While there is no doubt that the 
untoward effects noted by the pioneer 
clinicians were to a large extent due 
to the excessive doses employed, yet 


the second factor, i.c., the unrelia¬ 
bility of the preparations, was the 
greatest contributing element. H. H. 
Redfield (Med. Summary, Aug., 1915). 

Cancer is a blood disease which 
has resulted from persistent auto¬ 
toxemia. Healthy cell metabolism is 
gradually replaced by cell metamor¬ 
phosis, which results in these meta¬ 
morphosed cells departing from 
physiological control, and assuming 
the character of fungi. These grow 
upon and not zvitliin the tissue, as be¬ 
nign tumors do. Moreover, these are 
able to exist and thrive only upon a 
vitiated soil, which in this instance 
is the blood. Fungi likewise are 
able to exist only upon a polluted 
soil. So long as the thyroid gland 
is in a healthy condition healthy cell 
metabolism will continue; but this 
can only be the outcome of this 
gland and every other gland being 
supplied by non-toxic blood. Other¬ 
wise its functional activity will be re¬ 
duced, and so we invariably find that 
hypothyroidism is in existence. More¬ 
over, there also coexists atrophy of 
this gland in cancer subjects. Robert 
Bell (Med. Rec., Feb. 28, 1920). 

• For the time being, thyroid prepara¬ 
tions should be used only in absolutely 
inoperable cases, surgery having given 
far better results than any other 
method, including X-rays and thyroid 
preparations. In the second place, it 
is a mistake to attribute specific or 
even curative properties to thyroid 
preparations alone. They only assist in 
the curative process by facilitating pro¬ 
teolysis, i.e., breaking down of the 
growth. The detritus is such that after 
its use the kidneys are greatly exposed, 
and cases have been reported in which 
fatal nephritis followed the use of 
large doses. Such doses are, therefore, 
dangerous. Small doses do quite as 
well; but even when these are used 
the patient should be ordered to drink 
at least one quart of water daily, pref¬ 
erably a mineral water, to promote 


728 


ANIMAL EXTRACTS (SAJOUS). 


flushing of the kidney and thus facil¬ 
itate the elimination of toxic wastes 
and detritus. One or 2 grains of desic¬ 
cated thyroid three times daily usually 
suffice, but 3 grains can be given if no 
rise of temperature is observed. 

Case of multiple carcinoma of the 
skin and subcutaneous tissue in a 
widow aged 61. The original growth 
had been removed a year before the 
author saw the patient, but other 
growths had since appeared, and the 
patient’s health was declining. Thy¬ 
roid medication was tried, starting 
with 5 grains daily, gradually in 
creasing to 10 grains, and finally to 
15 grains, daily. The patient quickly 
showed signs of improvement; the 
palpitation, sickness, and emaciation 
gradually disappeared pari passu with 
the gradual disappearance of the 
growths. In less than three months 
the growths had entirely disappeared, 
the patient was practically well, and 
had recovered her lost weight of 3 
stone. This occurred in 1901, and at 
present the patient is still well and 
has not suffered since. The writer 
summarizes other and similar cases 
from medical literature. E. Hughes 
Jones (Brit. Med. Jour., Feb. 25, 
1911). 

Case of cancer of the larynx. The 
patient was a man 51 years of age who 
developed malignant disease of the 
larynx for which total extirpation of 
the larynx was done. After an attack 
of secondary hemorrhage the patient 
finally began to recover on the sixteenth 
day after the operation and gradual 
healing occurred. About three months 
later, a mass of glands over the right 
carotid sheath were found to be second¬ 
arily affected, and these were removed. 
He kept well for eight or nine months 
after this operation, and then recurrence 
of the growth took place and a lump as 
large as a walnut developed on the right 
side of the neck. An attempt was made 
to remove it, but it was found at the 
operation that the growth involved not 
only the common carotid artery, but the 
prevertebral muscles. Complete re¬ 


moval could be accomplished only by 
exposing a healthy portion of the com¬ 
mon carotid, ligating it, and dissecting 
the cancerous mass up from below and 
sacrificing the pneumogastric nerve, an 
. operation that would almost certainly 
have been fatal, while it gave little or 
no prospect of eradicating the disease. 
The lower portion of the mass involved 
the thyroid gland. Accordingly, the 
operation was abandoned except that a 
small portion was removed for micro¬ 
scopic examination. This proved to be 
cancerous. A few days later, the pa¬ 
tient was seen on consultation with Sir 
Charles Ball, who suggested that th}^- 
roid extract should be given and cited 
2 cases of inoperable cancerous lym¬ 
phatic glands in which that remedy had 
been tried with success. Three-grain 
doses of the extract were prescribed 
three times daily. At the end of four 
months’ treatment, there was distinct 
diminution in size of the glands. The 
thyroid extract was continued with the 
result that the growth finally disap¬ 
peared completely, and the patient be¬ 
came quite well. 

There is now a series of well-authen¬ 
ticated cases of cancerous recurrences 
on lymphatic glands cured by thyroid 
extract. R. H. Woods (London Letter, 
N. Y. Med. Jour., July 22, 1911). 

The other agents indicated as such 
as would be warranted were the same 
general symptoms met in other disor¬ 
ders. The anemia, which, with the gen¬ 
eral vasodilation and the resulting re¬ 
cession of blood from the surface, 
gives the patient the waxy pallor some¬ 
times observed, should be met by iron, 
preferably Blaud’s pill, and strychnine 
in full doses. In personal cases, by 
treatment based on general principles, 
using thyroid only when the growths 
seemed to take a fresh start, they have 
been kept in abeyance several years, 
six years in one case, four years in 
another. 

The same treatment is indicated in 
cases after operation to prevent recur- 


ANIMAL EXTRACTS (SAJOUS). 


729 


rence, the aim here being to enhance 
the functional activity of all organs, in¬ 
cluding those which govern the im¬ 
munizing processes. General tonics, 
especially iron and strychnine, and out- 
of-door life are of especial value in 
this connection. 

Cutaneous Disorders.—After a pro¬ 
longed trial of thyroid preparation in 
many diseases of the skin, dermatol¬ 
ogists have come to the conclusion 
that they were indicated in disorders 
due to deficient metabolism. As re¬ 
cently stated by Winfield, these in¬ 
clude the erythematobulbous type, 
which includes dermatitis herpetifor¬ 
mis, and the psoroeczematous type, to 
which belong prurigo, psoriasis, and 
chronic eczema. 

This is fully accounted for by the 
action of thyroid products on oxidation 
and metabolism I have described. 
This is well shown in the effects noted 
by Don: 1. Increased nutrition of the 
skin; hence its probable remedial action 
in ichthyotic conditions: an effect pro¬ 
duced without any necessary abnormal 
perspiration. 2. Increased action of the 
cutaneous glands, accelerating excre¬ 
tion of waste products, thus keeping 
the surface in a supple condition. 3. 
Regrowth of hair, as shown in myx¬ 
edema and some cases of general alo¬ 
pecia. 4. Increased activity of the epi¬ 
dermal layers, causing desquamation 
of unhealthy epidermis and reproduc¬ 
tion of a new covering, as observed in 
ichthyosis, psoriasis, dry chronic ec¬ 
zema, and also in some cases of myx¬ 
edema and cretinism. 

Series of consecutive cases of 
eczema in young children successfully 
treated by thyroid. In the first case, 
14 months old, the baby had suffered 
from eczema of the face for nearly 
a year. This had been entirely re¬ 
sistant to the usual applications and 


internal treatment, nor was hospital 
treatment more efficacious. Two and 
a half grains of a thyroid tablet were 
given daily. In a little more than one 
month the child was entirely well. 
His cure persisted for nearly a month, 
when the disease showed a tendency 
to recur. The second course of thy¬ 
roid was followed by a permanent 
cure. The 4 other cases gave similar 
results. Eason (Scottish Med. and 
Surg. Jour., May, 1908). 

Two cases of eczematous seborrhea 
successfully treated with thyroid. In 
the first case the scalp was normal at 
the end of two weeks; in the second 
in one month. Complete cure occurred 
in both cases, and has persisted. Mous- 
sous (Archives de med. des enfants, 
March, 1908). 

It is pretty certainly established that 
preparations from certain ductless 
glands exert a marked influence upon 
those dermatoses due to faulty metab¬ 
olism. There is a certain class of skin 
diseases, those belonging to the ery- 
thematobullous type and those of the 
psoroeczematous variety, in which the 
preparations coming under the head of 
animal therapy seem to do the most 
good. J. M. Winfield (Interstate Med. 
Jour., Nov., 1909). 

In psoriasis thyroid is harmful 
when the eruption is developing, but 
it sometimes acts with surprising effi¬ 
cacy in fully developed cases. The un¬ 
toward effects observed by dermatolo¬ 
gists, however, are in great part due 
to the fact that they use too large doses. 
These, as previously stated, enhance 
catabolism violently and increase the 
waste products in the blood and, there¬ 
fore, the cutaneous disorder. 

The writer treated 9 cases in this 
way, i.e., by the administration of 
thyroid extract alone. In 3 it re¬ 
moved all traces of the disease. One 
of the relieved cases had proven in¬ 
tractable to the orthodox methods of 
treatment, by arsenic, chrysarobin, 
etc. The other 2 patients presented 
typical pictures of an average case of 


730 


ANIMAL EXTRACTS (SAJOUS). 


psoriasis. In 3 of the cases thus 
treated the lesions retrogressed 
markedly, but never entirely disap¬ 
peared. In the remaining 2 the treat¬ 
ment had no appreciable effect. It 
was administered on the basis of its 
favorable influence on metabolism, 
J. E. Hays (Miss. Valley Med. Jour., 
Jan., 1918). 

Sajous states that a perfect secre¬ 
tion of the thyroid is necessary for, 
1, proper relationship of the amount 
of fat to the rest of the body; 2, 
proper nitrogenous metabolism of the 
body;. 3, proper health and functions 
of the skin and its appendages, hair, 
nails, etc. Hence, deficient secretion 
is apt to produce disturbances of skin 
functions and to interfere with the 
metabolism of proteins and fats. The 
skin being the largest fat organ in 
the body, therefore bears the brunt 
of the manifestations occurring in 
deficient thyroid secretion. It must 
therefore be conceivable that changes 
in the hormone producing organs, re¬ 
sulting in disorders of general nutri¬ 
tion as above mentioned, may influ¬ 
ence the evolution of such skin mani¬ 
festations as dermatoses and eczemas. 

In considering the treatment, it 
must be borne in mind that a child 
with deficient thyroid secretion has 
lessened metabolic powers; Magnus 
Levy, DuBois, and Talbout, who 
have experimented with metabolism 
of cretins, found it to be very much 
less than normal. Talbout found that 
the metabolism of a cretin lYi years 
old was about equal to a normal child 
8 months old. This means that we 
must give less food to these children 
at the beginning of treatment and in¬ 
crease the food with the improve¬ 
ment. 

Fairly large doses of thyroid should 
be administered at first, in order to 
remove results which have been pro¬ 
duced by privation of thyroid secre¬ 
tion. Later, smaller doses are given 
to maintain a normal equilibrium and 
prevent a recurrence. Following im¬ 
provement, the dose of thyroid which 
at first was sufficient later becomes 
an overdose, according to the writer. 


increasing the oxygenizing process, 
and the patient'begins to consume 
his own fat. Thyroid, therefore, 
should only be given when definitely 
indicated. 

If the lesions of the skin are re¬ 
garded as merely a symptom rather 
than a disease, greater progress will 
be made. In every obstinate skin 
manifestation, a thorough physical 
and cherriical examination of secre¬ 
tions and excretions is indispensable 
for determining the proper method of 
treatment. 

The clinical picture of disturbances 
of internal secretions should always 
be| kept in mind, for it is very impor¬ 
tant that they should always be esti¬ 
mated in connection with any other 
symptom, since upon the proper treat¬ 
ment of this factor usually depends 
success or failure. M. H. Edelman 
(N. Y. Medical Jour., Mar. 9, 1918). 

Thyroid has been tried in lupus by 
a number of observers. Though the 
results were contradictory, the bulk 
of the evidence indicates that it is 
worthy of further trial. Owing to its 
influence on oxidation, thyroid en¬ 
hances the nutrition of the skin and 
thus antagonizes the destructive proc¬ 
ess while promoting that of repair. As 
full doses have to be used during a 
prolonged period, the patient should 
be carefully watched. Thyroid has 
been tried in leprosy, but the results 
were not encouraging, though the 
remedy was pushed as far as safety 
would allow. 

In a case of hypertrophic rosacea 
which has resisted all forms of treat¬ 
ment, Isadore Dyer, of New Orleans, 
used thyroid with, for local use, a salve 
containing resorcin Dj; rose water, 
oiv; lanolin, q. s. ad gvj. After two 
months there was decided improvement, 
the skin being soft and normal to the 
touch and the color greatly improved. 


ANIMAL EXTRACTS (SAJOUS). 


731 


The patient was discharged cured after 
three months of thyroid medication. 

Exophthalmic Goiter or Graves’s 
Disease.—The results of treatment 
by thyroid preparations are reviewed 
under the heading of Graves’s Disease, 
in the fifth volume, the reader is re¬ 
ferred to that article. This applies 
also to Goiter, reviewed in full in the 
same volume. 

Hemophilia.—Thyroid preparations 
are extremely valuable in this dyscrasia, 
due to a deficiency of fibrin ferment in 
the blood. As this body, according to 
my researches, is mainly composed of 
the adrenal product, the increased 
functional activity of the adrenals pro¬ 
voked by thyroid preparations admin¬ 
istered increases the blood’s asset. The 
coagulation time in hemophilia may be 
brought down from over ten minutes 
to three or four minutes in adults by 
3-grain doses of the desiccated thyroid 
three times daily after meals. This is 
effective not only in the treatment of 
the disease, but also when operations 
are necessary in hemophilics. Even 
such operations as removal of a kidney 
have been resorted to with perfect 
safety after the coagulation time had 
been reduced to three minutes. 

Case in which hemophilic epistaxis 
was absolutely unaffected by ordinary 
therapeutic agents, and the epistaxis 
became so persistent and exhausting 
that permanent blocking of the nasal 
fossa was necessary. Treatment by 
thyroid extract exerted an immediate 
and beneficial effect, and was fol¬ 
lowed by cure. In three days the 
violent and persistent epistaxis had 
practically stopped. In six days, 
about 8 grains of thyroid extract 
having been given daily, the purpuric 
eruption ceased. Scheffler (Arch, de 
med. et de pharm. mil., March, 1901). 

Three cases of operations in 
“bleeders” in which the administra¬ 


tion of thyroid extract, for some days 
preceding operation, as advised by 
Sajous, was followed by remarkable 
results in lessening the hemorrhage 
at that time. Sajous holds that the 
thyroid extract stimulates the ante¬ 
rior pituitary body, which in turn 
excites the adrenals to greater activ¬ 
ity, thus augmenting the proportion 
of fibrin ferment in the blood, and 
consequently its coagulating power. 
This explains the action in these 
hemophilics, and its use is recom¬ 
mended as a preparatory treatment 
whenever surgical operation is to be 
undertaken in such persons. W. J. 
Taylor (Monthly Cyclo. of Tract. 
Med., July, 1905). 

Incontinence of Urine.—In a large 
number of these cases, the enuresis is 
due to general asthenia, and the mus¬ 
cular debility which attends this state 
carries along with it inability of the 
sphincters to perform their functions 
at all times, especially when during 
sleep general relaxation prevails. The 
influence of thyroid on general me¬ 
tabolism and nutrition and the result¬ 
ing increase of functional power in 
all organs affect equally both the 
cystic and urethral sphincters and 
thus overcome the trouble. The doses 
should be small in order to enhance 
general nutrition. 

Infectious Diseases.—So far thy¬ 
roid preparations have not been used 
to any marked extent in this class of 
disorders, but it is probable that they 
will eventually prove of great value 
owing to the identity of the thyroid 
secretion as opsonin, pointed out by 
myself in 1907, as previously stated. 
Several investigators, including Marbe. 
of the Pasteur Institute, have since 
found that the administration of thy¬ 
roid preparations to animals increased 
the opsonic power of the blood. 

The enlargement of the thyroid, 


732 


ANIMAL EXTRACTS (SAJOUS). 


which can be distinctly detected by 
palpation, and its erethism during in¬ 
fectious and other toxemias indicate 
that it fulfills active functions in the 
immunizing process. 

[The participation of the thyroid in gen¬ 
eral immunity pointed out by myself in 
1903 and since confirmed, we have seen, 
explains the overactivity of the thyroid in 
certain disorders. But, as I have re¬ 
peatedly emphasized in “Internal Secre¬ 
tions,” vol. ii, this applies only to those 
diseases which are capable through their 
toxins of exciting the thyroadrenal center, 
thus evoking a protective reaction on the 
part of the thyroid and adrenals. Various 
toxins and poisons are not only unable to 
excite this center, but can depress it. 
Hence the fact that in the conditions men¬ 
tioned (excepting septicemia, in which 
Vincent is wrong in his generalization) 
the thyroid gives no evidence, through 
tumefaction and tenderness, of overactiv¬ 
ity. C. E. DE M. S.] 

So far, thyroid preparations have 
been used in but few diseases. In 
true infectious tonsillitis, desiccated 
thyroid clears the field promptly. It 
does so, of course, by enhancing the 
bactericidal and antitoxic powers of 
the blood and glandular secretions. 
The bacteria being rendered more 
sensitive, that is to say, more easily 
(digestible, they readily become the 
prey of the phagocytes, which are ex¬ 
tremely numerous in the tonsils. 

Thyroid gland has also been em¬ 
ployed advantageously in septicemia 
and in recurrent erysipelas, i.e., in 
streptococcic infection. 

Pulmonary tuberculosis, before the 
disease is sufficiently advanced to 
compromise the mechanism of respi¬ 
ration, that is to say, during the first 
or incipient stage, is especially vul¬ 
nerable to the action of small doses 
of thyroid. As I urged in 1907, the 
tubercle bacillus, which is also patho¬ 


genic when dead, owes its morbid ac¬ 
tion to an endotoxin rich in phos¬ 
phorus; being thus prone to oxidation, 
while the blood’s oxidizing power is 
enhanced simultaneously, this bacil¬ 
lus is promptly destroyed. 

The daily administration of thyroid 
gland at a time corresponding to or 
preceding infection with tuberculosis, 
and in such doses as are well borne, 
causes an energetic acceleration of 
the metabolism of the organism and 
modifies favorably the action of the 
experimental tuberculous and pseudo- 
tuberculous infection in rabbits. The 
animals treated with thyroid gland 
live longer than the control animals, 
and in some cases life is prolonged 
indefinitely. Frugoni and Grixoni 
(Berl. klin. Woch., June 21, 1909). 

As stated above, it is only in the 
incipient stage that, as shown by per¬ 
sonal experience, thyroid gland is 
useful to check the morbid process. 
Later, it produces exhaustion owing 
to the excessive catabolism it awak¬ 
ens, even in very small doses. 

Insanity.—The idiocy of cretinism 
and the wonderful improvement that 
thyroid preparations bring about in 
young cretins suggest that a direct re¬ 
lationship must exist between the func¬ 
tion of the thyroid and the organ of 
mind, the brain. The functions I have 
ascribed to the thyroid to increase the 
vulnerability of phosphorus-laden cells, 
etc., to oxidation explain this beneficial 
action. Briefly, the thyroid preparation 
raises the ability of the cerebral cells 
to replace the sluggish metabolism and 
inadequate nutrition of which it has 
been the seat to the level of normal me¬ 
tabolism and nutrition. In other words, 
the cerebral cells, along with those of 
the entire organism, are caused to 
burn faster; the vital process being cor¬ 
respondingly more active, the function 
of the brain, as the seat of mental proc- 


ANIMAL EXTRACTS (SAJOUS). 


733 


esses, is sooner or later in youn^ sub¬ 
jects carried on with adequate vigor. 

Such being the case, we can only ex¬ 
pect benefit when increased metabo¬ 
lism and cell nutrition is required, i.e., 
in stuporous melancholias due to de¬ 
fective nutrition, depressive states in 
general, when organic lesions are not 
present. Again, in view of the prop¬ 
erty thyroid preparations possess of 
promoting the proteolysis or breaking 
down of waste products we should ex¬ 
pect benefit in puerperal and climac¬ 
teric insanities. Clinical observation 
has sustained this interpretation. As 
a rule, however, psychiatrists have 
used entirely too large doses; hence 
the untoward effects recorded. 

Lactation.—Thyroid preparations 
have been recommended as galacta- 
gogues by Hertoghe, Cheron, and oth¬ 
ers. In some cases on record the secre¬ 
tion of milk was free as long as thyroid 
was taken and failed as soon as it was 
neglected. This is obviously due to its 
stimulating influence on general oxida¬ 
tion, all functions being enhanced. 

Middle-ear Disorders.—Thyroid 
preparations have been tried in several 
of these disorders, sclerosis, middle-ear 
catarrh, ossicular sclerosis, etc., but the 
results, on the whole, were not encour¬ 
aging. They should be tried, however, 
in suppurative processes associated 
with general adynamia, as these often 
persist merely because the bactericidal 
and antitoxic powers of the blood are 
deficient. Thyroid, by enhancing these 
protective functions, has at least proven 
valuable in ulcerative disorders located 
elsewhere, even when osseous tissue 
was involved, as in osteomyelitis. 

Nervous Disorders.—Epilepsy.— 
This disease is sometimes greatly bene¬ 
fited by the use of thyroid prepara¬ 
tions, but only when small doses are 


used. Untoward results are readily 
caused by excessive dosage, as shown 
by loss of weight. Coincidently, meat 
should be removed from the diet, and 
the patient ordered to drink copiously 
of water. The spasmogenic wastes are 
thus increasingly broken down by the 
thyroid; they are formed less freely 
owing to the abstraction of meat, and 
the end products of metabolism are 
more readily eliminated by the kidneys 
owing to the free use of water. I have 
observed excellent results through this 
treatment. It must not be forgot¬ 
ten, however, that other factors— 
intestinal worms, indigestible foods, 
scars, dentition, alcohol, lead poison¬ 
ing, syphilis, nasal growths, dental 
interpressure, and phimoses—may pro¬ 
duce epilepsy, and that the cause must 
be removed in such cases if a satisfac¬ 
tory result is to be obtained. 

A conclusion forces itself upon us, 
viz., that idiopathic epilepsy is always 
associated with defective metabolic 
processes. The latter may originate 
from many sources. There is a cer¬ 
tain class of epileptics whose seiz¬ 
ures are in direct relationship with a 
disturbed function of the ductless 
glands and particularly the thyroid. 
In such cases the reason for failure of 
the usual treatment lies in the want 
of thyroid feeding. Administration 
of the latter will be of great benefit. 
Six illustrative cases. Alfred Gordon 
(Penna. Med. Jour., July, 1908). 

Three cases of epilepsy in which 
the simplifying influence of Dr. 
Sajous’s discoveries as to the func¬ 
tions of the ductless glands and other 
body structures is clearly shown by 
good results. All three being due to 
the retention of excrementitious sub¬ 
stances in the blood, and the irritat¬ 
ing action of these poisons upon the 
spasmogenic centers—the indications, 
of course, were to destroy these 
poisons. Drugs known to do so by 
increasing the antitoxic substances 
through the ductless glands—mer- 


734 


ANIMAL EXTRACTS (SAJOUS). 


cury and desiccated thyroid—were 
administered. To assist this antitoxic 
process of the osmotic properties of 
the blood, physiological saline solu¬ 
tion was given as beverage. On the 
other hand, the sources of intoxica¬ 
tion were as much as possible elimi¬ 
nated by purgation and dietetic meas¬ 
ures calculated to prevent the accu¬ 
mulation in the blood-stream of any 
toxic wastes, i.e., wastes imperfectly 
prepared for prompt elimination by 
the kidneys. J. Madison Taylor 
(Monthly Cyclo. of Pract. Med., 
March, 1909). 

When epilepsy is complicated by 
bromism this may be combated with 
thyroid gland. A cachet 0.1 Gm. 
0y2 grains) of desiccated thyroid is 
given every morning for three weeks, 
then suspended from time to time for 
a fortnight. Two doses, each of 1 
Gm. (15 grains) of potassium bro¬ 
mide, are given daily at equal inter¬ 
vals, say at 10 a.m. and 10 p.m., apart 
from meals, and dissolved in half a 
wineglassful or less of water. The 
bromide is to be given regularly with¬ 
out suspending the treatment. J. A. 
Sicard (Jour, de med. de Paris, Nov. 
19, 1910). 

Two cases of cretinism in twin 
brothers, both of whom suffered in 
addition, one from epileptic seizures, 
the other from a marked degree of 
ataxia. The epileptic attacks began 
at the age of 23 and rapidly increased 
in frequency until they were of al¬ 
most daily occurrence; there were 
occasional attacks of petit mat be¬ 
sides the seizures of grand mat. The 
attacks were greatly modified by thy¬ 
roid therapy, although this patient 
could not tolerate more than 25 
grains of the extract daily. The 
other twin, when 14 years old, de¬ 
veloped a staggering gait, walking 
like a drunken man, and suffering 
severe pains about the hips; the arms 
soon became involved so that he 
could hardly write. This patient be¬ 
gan by taking 15 grains of thyroid 
extract a day, and the dose was in¬ 
creased gradually until he was taking 
45 grains a day without toxic mani¬ 


festations. All his symptoms im¬ 
proved, including the ataxia; he is 
able to walk (though with a wad¬ 
dling movement) and to write, earn¬ 
ing his living by typewriting. L. S. 
Manson (Med. Record, Jan. 1, 1910). 

A considerable number of cases of 
epUepsy present symptoms of endo¬ 
crine disorder which stand out more 
or less prominently. The administra¬ 
tion of thyroid gland was found in 
some instances to have true therapeu¬ 
tic value. H. H. Drysdale (Ohio 
State Med. Jour., xii, 802, 1916). 

In some cases of epilepsy the ad¬ 
ministration of small doses of thyroid 
gland (Vs to ^ grain—0.008 to .0.016 
Gm.—three times a day) for long 
periods seemed to raise the patient’s 
physiological level with marked bene¬ 
fit, thus permitting them to respond 
more favorably to other treatment. 
The diet should be so modified that 
the organism, already toxic, should 
be put to as little strain as possible, 
especially the liver, thyroid and other 
defensive glands. F. X. Dercum 
(Jour. Amer. Med. Assoc., Ixvii, 247 

1916) . 

In cases of combination of epilepsy 
and tetany one has to examine care¬ 
fully, whether the cause of these dis¬ 
eases is an insufficiency of the thy¬ 
roid and parathyroid glands. Only in 
this case were very good results ob¬ 
tained from rectal applications of 
fresh thyroid and parathyroid glands 
at the same time. In other cases, 
however, not due to insufficiency of 
the thyroid-parathyroid system no 
effect can be expected from this 
treatment. G. C. Bolten (Genees- 
kundige Bladen, Haarlem, xix 301 

1917) . 

Eclampsia.—It is now generally rec¬ 
ognized that this complication of the 
puerperal state is due to toxemia. Thy¬ 
roid extract is indicated, therefore, 
since it enhances the destruction of 
toxic wastes and other poisons. 

This accounts, from my viewpoint, 
for the fact that a number of cases 
have been reported in which the con- 


ANIMAL EXTRACTS (SAJOUS). 


735 


vulsions ceased under the influence of 
rather large doses of thyroid gland. 
Nicholson obtained excellent results 
with grains of thyroid extract every 
three or four hours, with morphine as 
an adjunct. Baldowsky confirmed its 
value in 2 cases; in the first, a multi- 
para in the seventh month of preg¬ 
nancy, a convulsion occurring, 18 grains 
of thyroid extract were given. The fits 
ceased. The thyroid was continued for 
two days longer—10 grains daily—and 
the patient seemed quite recovered. A 
fortnight later she again developed se¬ 
vere eclamptic fits, sixteen seizures al¬ 
together, which were treated by thy¬ 
roid extract, with narcotic remedies, 
and recovery followed. The other was 
a primipara at term who was suddenly 
seized with convulsions at the com¬ 
mencement of labor. Thyroid extract 
alone was given, and the attack ceased 
before the rupture of the membranes. 
The labor took place without any un¬ 
usual symptom, and the puerperium 
was normal. 

I have pointed out, however, that the 
action of the thyroid is greatly enhanced 
by the simultaneous use of hypodermo- 
clysis. In some cases the thyroid 
preparation was dissolved in the saline 
solution injected. 

Migraine.—This disorder is now 
generally attributed to the gouty diath¬ 
esis, i.e., to the accumulation in the 
blood of intermediate waste products 
of the purin or alloxuric type. Thy¬ 
roid preparations, by promoting the 
conversion of these toxic products into 
bodies that are readily eliminated by 
the kidneys, antagonize this pathogenic 
process. But here, again, small doses 
are alone indicated; 1 or 2 grains (0.6 
to 0.13 Gm.) of desiccated thyroid 
during meals suffice at first, the efifect 
being kept up after a few weeks by a 


single grain daily. The free use of 
water as beverage, abstention from red 
meats, and out-of-door exercise are 
necessary accompaniments to obtain 
the best results. 

Asthma.—A certain proportion of 
these cases is also, as is well known, a 
manifestation of the gouty diathesis. 
Hence, the value of thyroid prepara¬ 
tions owing to the antitoxic action 
which renders them useful in migraine. 

Tetanus.—As thyroid preparations 
promptly arrest the tetanus that occurs 
after removal of the thyroid, they 
suggest themselves not only as pro¬ 
phylactics, but also to assist teta¬ 
nus antitoxin. The latter sometimes 
fails merely because the spasmogenic 
poisons are not sensitized or “opso¬ 
nized” to its effects, as shown by a com¬ 
paratively low temperature; desiccated 
thyroid in full doses tends to correct 
this condition and to increase the 
chances of recovery. 

Osseous Disorders.—As far back as 
1897 Gabriel Gauthier showed that 
delayed union in fractures was coun¬ 
teracted by thyroid preparations, con¬ 
solidation occurring in some instances 
as early as the fifteenth day. Similar 
results have been obtained by many 
observers, the proportion of success¬ 
ful cases being about 60 per cent. 
Removal of the thyroid had been 
found by Hanan, Steinlein, and Bayon 
to prevent the healing of fractures in 
otherwise healthy animals, thus af¬ 
fording a sound basis for the use of 
thyroid preparation. Its beneficial 
effects are best shown in the young, 
its value decreasing as the patient is 
more advanced. 

Thyroid preparations have also been 
used with success in osteomalacia, 
rickets, and osteomyelitis. All these 
beneficial effects are explained by the 


736 


ANIMAL EXTRACTS (SAJOUS). 


influence of thyroid on metabolism, all 
functions, including the processes of 
repair, being enhanced. The marked 
influence of the thyroid over calcium 
metabolism shown by Parhon, Macal- 
lum, and others is another potent 
factor in the marked benefit noted in 
these disorders. 

Rheumatism, Chronic Progressive. 
—Following the experience of Revil- 
liod, Lancereaux has urged the value 
of thyroid preparations in this class of 
disorders many years, but, as is often 
the case, the scoffers of the profession 
have caused the valuable observations 
of both these distinguished clinicians 
to be ignored, thus perpetuating need¬ 
lessly the acute sufferings of the many 
victims of this disease. When its path¬ 
ogenesis is interpreted from my stand¬ 
point (see “Internal Secretions” Suppl., 
p. 1869, 1907), i.e., “inadequate catabo¬ 
lism of tissue wastes and excitation by 
the toxic products formed of the vaso¬ 
motor center,” the favorable influence 
of thyroid preparations is self-evident: 
the toxic wastes which provoke excess¬ 
ive vascular tension and pain being 
more actively broken down, the pri¬ 
mary cause of the disorder is removed. 
Souques (1908), in 2 cases of this dis¬ 
ease, found the thyroid gland atro¬ 
phied. Many cases have recently been 
treated successfully. Leopold-Levi and 
de Rothschild, who have had the great¬ 
est experience with this class of cases, 
recommend—in keeping with the teach¬ 
ings of my own experience, and now 
sustained by the experience of many 
other clinicians — that small doses 
should be used. 

[As Rachford observed over twenty 
years ago “thyroid feeding will increase 
the excretion of the alloxuric bodies in 
the urine, and will produce an acute ar¬ 
thritis in a patient suffering from chronic 


rheumatic gout.” Large doses will thus 
prove harmful where small doses will 
prove beneficial. C. E. de M. S.] 

Case of a man who had suffered 
for thirty-six years from rheumatism 
and gout, with decided arterioscle¬ 
rosis, high-tension pulse, heart hy¬ 
pertrophied, and albuminuria, who 
under the influence of Baumann’s 
iodothyrin, started with ^4 Gm. daily 
—increasing % Gm.—was relieved of 
the pain in the limbs, polyuria and 
albuminuria controlled, the heart im¬ 
proved, tension of the pulse lessened, 
although it was more rapid. Lance¬ 
reaux and Paulesco (Bulletin de 
I’Acad. de Med., Jan. 3, 1899). 

Uterine Disorders.—Various con¬ 
ditions of the genital apparatus, such 
as the onset of puberty, pregnancy, 
fibroid tumor, which cause a distinct 
change in the metabolism of the entire 
organism, frequently produce enlarge¬ 
ment of the thyroid gland. Again, 
the deficiency of the normal thyroid 
secretion following thyroidectomy in 
myxedema, cretinism, etc., is often 
associated with atrophic changes in 
the genital apparatus, as shown by 
Fisher, of Vienna 

This clearly indicates direct associa¬ 
tion between the thyroid and the genital 
system, and has suggested the use of 
thyroid preparations. The vomiting 
of pregnancy is also benefited by 
their use. 

They have been found of value for 
the purpose of arresting hemorrhage, 
whether this occur in connection with 
abortion, tumors, or uterine malposi¬ 
tions. A remarkable case of metror¬ 
rhagia due to hemophilia successfully 
treated with thyroid extract was re¬ 
ported by Dejace. In the disorders 
of menopause, hemorrhages, flushes, 
irritability, migraine, etc., thyroid 
preparations are of undoubted value 
owing to their ability to promote the 


ANIMAL EXTRACTS (SAJOUS). 


737 


destruction of waste products, which 
underlie these morbid phenomena. 

It is very probable that the toxemia 
of pregnancy is largely dependent 
upon faulty metabolism; at least, an 
insufficient metabolism is an accom¬ 
paniment which greatly adds to the 
seriousness of the condition. Failure 
of the thyroid gland to hypertrophy 
during pregnancy is probably fol¬ 
lowed by insufficient metabolism, and 
may result in the various forms of 
toxemia of pregnancy. When there 
is a failure of the normal hyper¬ 
trophy of the thyroid gland during 
pregnancy and when there is a dis¬ 
eased thyroid, as in Graves’s disease, 
the administration of thyroid sub¬ 
stance, by supplying the deficiency of 
the normal thyroid secretion and by 
diuretic action, may materially im¬ 
prove a faulty metabolism and thus 
give a favorable influence upon the 
manifestations of the toxemia of 
pregnancy. Ward (Surg., Gynec. and 
Obstet., Dec., 1909). 

The writer observed 6 cases of 
uterine hemorrhage in which no pel¬ 
vic disease was discernible, which 
yielded to treatment with thyroid 
gland. Salzmann (Amer. Jour. Ob¬ 
stet., vol. Ixxiv, 812, 1916). 

Summary.—Thyroid preparations 
have been used and recommended in 
many other diseases, but the fore¬ 
going- seem to me to represent those 
in which they are productive of real 
good. My own experience has sug¬ 
gested that this would prove true, 
particularly as to desiccated thy¬ 
roid :— 

1. In diseases due to slowed de¬ 
struction of toxic wastes, as shown 
by its action in tetany, epilepsy, 
eclampsia, disorders of menopause, 
asthma, chronic rheumatism, mi¬ 
graine, and also by those due to slow 
oxidation of fats, as in obesity and 
Dercum’s disease: adiposis dolorosa. 

2. In diseases due to lowered gen¬ 


eral nutrition of all tissues, including 
the bones, as shown by its action in 
cretinism, myxedema, and kindred 
disorders—osteomalacia, rickets, and 
osteomyelitis. 

3. In disorders due to lowered nutri¬ 
tion of the muscular elements, including 
the skeletal and vascular muscles, as 
shown by its action in general adyna¬ 
mia, neurasthenia, and myasthenia. 

4. In all cases in which the processes 
of repair or absorption are deficient, as 
shown by its action in delayed union 
of fractures, certain benign and ma¬ 
lignant neoplasms, and syphilitic tis¬ 
sue and bone necrosis. 

5. In infectious diseases—owing to 
the increase of autoantitoxin, thyro- 
iodase (opsonin), and phagocytes—as 
shown by its action in tuberculosis, 
typhoid fever, infectious tonsillitis, 
certain exanthemata, and, in general, 
infections in which fever is a prom¬ 
inent symptom. 

PARATHYROID ORGANO¬ 
THERAPY. 

The two internal of these four small 
granules were described, as previously 
stated, by Sandstrom in 1880, while the 
two external were discovered by Nich¬ 
olas in 1893, and also in 1895 by Kohn. 
Though distinct from the thyroid 
gland, they are in close apposition to, 
and sometimes imbedded in, this organ, 
and are supplied mainly by the inferior 
thyroid artery. Though histologically 
different from the thyroid gland, they 
also contain a colloid substance in 
which iodine occurs in relatively large 
proportion. That they carry on some 
general function is shown by the fact 
that their removal causes tetany, while 
removal of the thyroid divested of its 
parathyroids causes myxedema, arrests 
growth, and impairs calcium metabo- 


738 


ANIMAL EXTRACTS (SAJOUS). 


lism, the bones, including the teeth, be¬ 
coming soft and brittle. 

The functions of the parathyroids 
are still in doubt; some investigators 
claim that they have no independent 
function; others that they govern cal¬ 
cium metabolism independently of the 
thyroid. A third group, to which my 
own researches have caused me to be¬ 
long, believe that they supply a secre¬ 
tion which combines with that of the 
thyroid to carry on the functions of the 
latter, i.e., to sustain tissue and calcium 
metabolism besides carrying on their 
antitoxic functions. From my view¬ 
point their secretion plays the principal 
role in the formation of Wright’s op¬ 
sonin in conjunction with the thy¬ 
roid, as shown under the preceding 
heading. 

[The investigations of King, Biondi (Berl. 
klin. Woch., xxv, p. 954, 1888), Zielinska 
(Virchow’s Archiv, cxxxvi, p. 170, 1894), 
Vassale and de Brazza (Arch. ital. di biol- 
ogia, xxiii, p. 292, 1895) on the thyroid, and 
those of Welsh (Jour, of Anat. and Physiol., 
April, 1898), and Capobianco and Mazziato 
(Giorn. Int. de Scienze, Nos. 8, 9, and 10, 
1899), and others on the parathyroids, have 
shown that the product of these organs 
passes into perivascular lymph-spaces. Beiitg 
then transferred to the larger cervical lym¬ 
phatics, they are discharged by the right and 
left lymphatic ducts—^the thoracic duct, ac¬ 
cording to Pembrey (Hill’s “Recent Ad¬ 
vances in Physiology,” p. 579)—into the sub¬ 
clavian veins, and by way of the superior 
vena cava to the heart. Here they become 
merged with the venous blood of the entire 
organism, forming a single secretion—in 
accord with Gley’s (La Presse medicale, 
January 12, 1898) view—which is then in¬ 
evitably carried to the heart, and thence to 
the lungs. As the venous blood carrying the 
secretion passes to these organs to be oxy¬ 
genized, the secretion itself is likewise car¬ 
ried to the air-cells. 

The purpose of this itinerary suggests 
itself when we recall that, as stated by Noth- 
nagel and Rossbach (Therapeutique, p. 261, 


1889), hemoglobin can fix large quantities of 
iodine. It accounts also for the fact that 
Gley (La Semaine medicale. May 25, 1898) 
and Bourcet found iodine in the red corpus¬ 
cles. Being a component of the albuminous 
hemoglobin of these cells with adrenoxidase, 
however, iodine should be found in all tis¬ 
sues. While Bourcet (cited by Morat and 
Doyon, Traite de physiologie, vol. i, p. 470, 
1904) ascertained that such was the case, 
Justus (Virchow’s Archiv, clxxvi, p. 1, 1904) 
found it in all cellular nuclei. This latter 
feature is important, since, as we have seen, 
iodine serves to increase the inflammability, 
as it were, of the phosphorus which all nuclei 
contain. C. E. de M. S.] 

THERAPEUTICS.— The actual 
value of parathyroid in therapeutics 
has not as yet been clearly deter¬ 
mined. It has been tried with benefit 
in postoperative tetany by several 
clinicians. MacCallum found large 
quantities injected intravenously nec¬ 
essary. Vassale, James, and Halsted 
have also had favorable results. While 
Birch found thyroid ineffectual, para¬ 
thyroid caused recovery. 

The nucleoproteid of the parathyroid 
relieves the symptoms of acute tetany 
in dogs, but the globulin has no such 
power. Boiling or heating the nucleo¬ 
proteid solution at 80® C for half an 
hour destroys its activity, and it de¬ 
teriorates rapidly when kept in solu¬ 
tion or frozen. The nucleoproteid 
relieves tetany by the mouth, but 
more effectively when given subcu¬ 
taneously or intraperitoneally. Berk¬ 
eley and Beebe (Jour. Med. Re¬ 
search, Feb., 1909). 

Three cases found in literature 
and 1 personal case in which the 
transplantation of human parathy¬ 
roids was followed by recovery. 
Danielson (Beitrage z. klin. Chin, 
Bd. xxxvii, S. 998, 1910). 

In postoperative parathyroid tetany 
—which is prevented by removing 
only, as does Kocher, the central part 
of the thyroid, thus leaving intact the 
posterior capsule, to which the para- 


ANIMAL EXTRACTS (SAJOUS). 


739 


thyroids adhere—the spasms may he 
arrested by implanting human thyroids 
from persons who have just died of 
some non-infectious disease. Implanted 
glands do not act at once; it is only 
when they assume their normal func¬ 
tions in situ that recovery occurs. 

Study undertaken with a view to 
determine the course to be pursued 
by the surgeon when a parathyroid 
gland has been accidentally removed 
or deprived of its blood supply, and 
in the hope that it might be attended 
with such success as to justify the 
attempt to transplant this glandule 
from man to man. The transplanta¬ 
tions were made either into the thy¬ 
roid, the spleen, or in or behind the 
rectus muscle of the abdomen, and 
were both auto- and iso- transplanta¬ 
tions. The writer’s deductions were 
as follows:— 

1. The autotransplantation of para¬ 
thyroid glandules into the thyroid 
gland and behind the musculus rec¬ 
tus abdominis has been successful in 
61 per cent, of the cases in which a 
deficiency greater than one-half has 
been created. 

2. In no instance has the auto¬ 
transplantation succeeded without 
the creation of such a deficiency. 

3. Isotransplantation has been uni¬ 
formly unsuccessful. 

4. Parathyroid tissue transplanted 
in excess of what is urgently re¬ 
quired by the organism has not 
lived. 

5. One parathyroid autograft may 
suffice to maintain the animal in 
good health and spirits for many 
months and possibly for years. 

6. Excised or deprived of their 
blood supply in the course of opera¬ 
tion upon the human subject, para¬ 
thyroid glands should, in the present 
State of our knowledge, be grafted, 
and probably into the thyroid gland. 

7. Complete excision of the thyroid 
lobes in dogs may be well borne for 
a year or more. The myxedema, 
which usually has manifested itself 
within a few weeks, has not increased 


after the first few months. May it 
subsequently diminish with the hy¬ 
pertrophy of accessory thyroids? 

8. Parathyroid tissue is essential to 
the life of dogs, as has been conclu¬ 
sively proven by the result of ex¬ 
cision of the sole sustaining graft. 
W. S. Halsted (Jour, of Exper. Med., 
vol. xi. No. 1, 1909). 

The indifference of some surgeons 
in respect to the importance of these 
parathyroids merits severe criticism. 
Personal case which, their advice be¬ 
ing followed, developed very severe 
tetany. The case was saved, only 
after all other measures had been 
tried in vain, by the implantation of 
a thyroid with its parathyroids, ob¬ 
tained from a small monkey and, one 
month later, of 3 parathyroids and a 
piece of thyroid the size of a small 
walnut, all obtained one-half hour 
after death from the body of a man 
who had died of Bright’s disease and 
uremia. These tissues, placed at 
once in normal saline solution at 32° 
F. (0° C.), were implanted success¬ 
fully within an hour, the simian thy¬ 
roid beneath the patient’s sternomas- 
toid, and the human thyroid and 
parathyroid beneath her left rectus 
abdominis, under chloroform anes¬ 
thesia. W. H. Brown (Annals of 
Surg., March, 1911). 

An emulsion of fresh parathyroids 
may also arrest the spasms, but obvi¬ 
ously only as long as the injected emul¬ 
sion is active. It is administered in 
saline solution subcutaneously. It may 
prove curative, as in the case cited be¬ 
low, but here the parathyroids were 
orriy partly removed, the recovery be¬ 
ing eventually due to the resumption of 
function by the latter. 

Case treated successfully by means 
of an emulsion of parathyroids given 
subcutaneously. Five fresh beef 
parathyroids were placed in a 1: 1000 
solution of bichloride of mercury and 
allowed to soak about ten minutes. 
The glands were cut, under strict 
asepsis, into 5 pieces under physio- 


740 


ANIMAL EXTRACTS (SAJOUS). 


logical salt solution. These pieces 
were placed in a mortar and ground 
into a homogeneous mass, 400 c.c. of 
sterile salt solution being poured into 
the mortar. This was then filtered 
and given as salt transfusion into 
the patient’s breast. The oral use 
of thyroid and parathyroid extract 
and the feeding of raw parathyroids 
had proved entirely useless. Only 1 
parathyroid had been entirely re¬ 
moved, and the 3 others only partly 
so. Branham (Amer. Jour. Med. 
Sci., vol. xlviii, p. 161, 1908). 

[In this case the injured parathyroids 
recovered and resumed their functions. 
The emulsion only served, therefore, to 
compensate for the temporary absence of 
secretion following the partial destruc¬ 
tion of the three parathyroids and did not 
itself bring on recovery. C. E. de M. S.J 

Meat should not be given to such 
cases, since it increases the tetany. The 
diet should be limited to milk, farina¬ 
ceous foods, and fruit. Exercise is 
harmful by promoting the formation of 
spasmogenic waste products. Rest in 
bed or in an armchair tends to reduce 
the frequency and violence of the 
spasms. 

Vassale claims that the parathyroid 
extract relieves eclampsia as certainly 
as thyroid does myxedema, while 
Berkeley tried it with some degree of 
success in paralysis agitans. The lat¬ 
ter gives 5 to 8 glands per day, minced 
and eaten in a bread-and-butter sand¬ 
wich. 

The writer has treated in consulta¬ 
tion and in his own practice 60 
cases of paralysis agitans with para¬ 
thyroid. Of these between 60 and 
65 per cent, who have given the 
remedy a fair trial have spoken 
favorably of it and have continued 
the treatment. More than a dozen 
who began three or four years ago 
have greatly improved and are now 
only uncomfortable when they are 
without the medicine. The writer 
concludes that with such a percent¬ 


age of benefited cases as this there 
seems no longer any reasonable 
doubt of the etiological relation be¬ 
tween the disease and the remedy. 
One or 2 cases in the hands of medi¬ 
cal friends or correspondents appear 
to be almost cured, though of such a 
disease in a patient of advancing 
years a “cure” is always to be spoken 
of with reserve. Berkeley (Med. 
Record, Dec. 24, 1910). 

Simonine also speaks of encourag¬ 
ing results in Sydenham's chorea (5 
cures), but the remedy has been tried 
by too few observers to warrant a con¬ 
clusion as to its actual value. 

ADRENAL OR SUPRARENAL 
ORGANOTHERAPY. 

Brown-Sequard showed in 1856 that 
death followed removal of both adre¬ 
nals in from a few hours to three days 
after a series of general phenomena 
corresponding to those of Addison’s 
disease, viz., steady decline of the blood- 
pressure, intense prostration, and mus¬ 
cular weakness. This observation was 
not only confirmed by many other in¬ 
vestigators, but Oliver and Schafer, 
Szymonowicz, and Cybulski showed 
that adrenal extract caused a marked, 
though ephemeral rise of the blood- 
pressure and increased the power of 
the cardiac contractions. This was at¬ 
tributed to a direct action on the mus¬ 
cular elements of the arterioles and on 
the cardiac muscle, all tissues inner¬ 
vated by the sympathetic system. On 
the whole the function of the adrenals 
was thought to contribute to the main¬ 
tenance of the normal blood-pressure 
and to sustain the tone of the tissues 
thus innervated. 

[Although the above is the view gen¬ 
erally taught concerning the role of the 
adrenals, physiologists themselves have 
recently reached the conclusion that it is 
erroneous. In a summary of the whole 
question in the April, 1917, number of 


ANIMAL EXTRACTS (SAJOUS). 


741 


“Endocrinolo{?y,” Professor Swale Vin¬ 
cent concludes, for instance, that “we 
know nothing of the functions of the ad¬ 
renal body regarded as an organ on its 
own account.” Not only is the blood- 
pressure theory of Oliver and Schaefer 
shown to be fallacious by recent experi¬ 
ments, but the antitoxic theory of Abel- 
ous and Langlois in virtue of which cer¬ 
tain toxic substances are destroyed by the 
adrenals likewise. “It must be confessed,” 
writes Vincent in this connection, “that 
the antitoxic theory has not been sub¬ 
stantiated.” 

As is well known, I have attributed en¬ 
tirely different functions to the adrenals 
since 1903. As shown below, these have 
been experimentally and clinically sus¬ 
tained. C. E. DE M. S.] 

The investigations of Young and 
Lehmann, Austmann and Halliday, 
Moore and the more recent observa¬ 
tions of Hoskins and McClure, among 
others, have shown, however, that it is 
not the function of the adrenals to 
maintain the blood-pressure, since the 
amount of their secretion poured into 
the adrenal veins tends to lower it. 
When, however, the blood-pressure is 
morbidly reduced, adrenal extract, ad¬ 
renalin or any active principle, acting 
pharmacologically, will tend to raise it. 

A quick rise in the blood-pressure 
of dogs was followed by a rapid fall 
and a secondary rise when adequate 
doses of adrenalin were administered 
intravenously (0.5 to 1 c.c.—8 to 16 
minims^—of 1: 10,000). After study¬ 
ing various hypotheses to account for 
this, the writers conclude that the 
primary rise is due entirely to peri¬ 
pheral action, and the secondary rise 
apparently to a central action of the 
adrenalin acting through the sym¬ 
pathetic ganglions. This central 
action can be prevented by pithing of 
the brain or removal of the head. 
McGuigan and Hyatt (Jour. Pharm. 
and Exper. Therap., Sept., 1918). 

To determine whether the dilator 
action of adrenalin was confined to 


carnivorous animals, the writers 
studied its action on the following 
species: snapping turtle, fowl, opos¬ 
sum, horse, goat, cats and dogs, fer¬ 
ret, raccoon, rats, rabbits and mon¬ 
keys. This extensive study led them 
to conclude that the usual vasomotor 
reaction in skeletal muscle was dila¬ 
tation with moderate doses of ad¬ 
renalin, except in the case of rodents; 
and because of the uniform occur¬ 
rence in other mammalian orders, as 
well as the presence in the monkey, 
it was believed that these mechanisms 
were also present in man. Hartmann, 
Kilborn and Lang (Endocrinology, 
Apr.-June, 1918). 

Ether anesthesia has a marked in¬ 
fluence in diminishing the pressor re¬ 
sponse to minute amounts of adre¬ 
nalin injected directly into the cir¬ 
culation. Hemorrhage also acts to 
lessen or abolish the response, and to 
a degree directly proportional to the 
lowering of the blood-pressure it 
causes. In the exsanguinated animal 
an amount of adrenalin 3 or 4 times 
that sufficient to produce a pressure 
rise of 10 to 15 mm. of mercury, under 
normal conditions, may be entirely 
without effect. The response to large 
doses, on the other hand, is uninflu¬ 
enced by ether or hemorrhage. These 
facts have a practical bearing not only 
on the employment of adrenalin to 
tide over collapse, but on its possible 
utilization in the future to raise a low, 
blood-pressure to the normal height 
and maintain it during a considerable 
period. The amount of adrenalin 
which under normal conditions will 
suffice to bring* up the blood-pressure 
may have little or no effect on an 
etherized individual or on one who 
has lost blood. Rous and Wilson 
(Jour, of Exper. Med., Feb., 1919). 

Blum and other experimenters have 
found that adrenal extractives cause 
glycosuria by enhancing carbohydrate 
metabolism, while Josue has shown 
that they provoke arteriosclerosis, an 
observation confirmed by many investi¬ 
gators. 


742 


ANIMAL EXTRACTS (SAJOUS). 


The action of adrenal preparations 
is exercised upon involuntary muscles 
—those of the vessels, heart, intestines, 
and uterus, for example. But, accord¬ 
ing to the prevailing view, this action 
may be antagonistic; it may inhibit the 
action of the intestines, act as mydriatic 
and promote the secretory activity of 
the lachrymal and salivary glands. 

PHYSIOLOGICAL ACTION.— 
Personal researches, including a large 
number of experimental and clinical 
facts found in literature led me to the 
conclusion in 1903 that the physio¬ 
logical function of the adrenal secretion 
was (1) to take up the oxygen of the 
air in the pulmonary alveoli and carry 
this gas to the tissues as a constituent 
of the oxyhemoglobin, and (2) that it 
was the adrenal secretion which, as far 
as the role of oxygen in these processes 
is concerned, sustained oxidation and 
metabolism. 

Referring the reader to the article on 
‘'Adrenals, Diseases of,” in this volume 
and to my work on the “Internal Secre¬ 
tions and the Principles of Medicine,” the 
main factors determined by my investiga¬ 
tions were briefly: (1) that the secretion 
of the adrenals has a marked affinity for 
oxygen, and that, owing to its passage 
into the inferior vena cava, it is inevitably 
carried to the pulmonary air-cells; (2) that 
once here it absorbs oxygen—thus fulfill¬ 
ing the role of a secretion deemed neces¬ 
sary by various physiologists (Paul Bert, 
Muller, Bohr, Haldane and Lorrain Smith, 
and others) to account for pulmonary 
respiration; (3) that it becomes, also in 
this location, the albuminous (96 per cent) 
constituent of hemoglobin and the red 
corpuscles, the identity and source of 
which physiologists have failed to identify, 
and (4) that this albuminous constituent 
of the hemoglobin which I have termed 
“adrenoxidase” owing to its source, the 
adrenals, and to its identity as oxidase, is 
distributed by the red corpuscles to all 
parts of the body as an oxidizing sub¬ 
stance. 


[The essential feature is whether the 
adrenal product can, as I have held, con¬ 
vert the hemoglobin of venous blood into 
the oxyhemoglobin of arterial blood. 
This has been sustained lately by Menten 
(Amer. Jour, of Physiol., vol. xliv, p. 176, 
1917) who found that the addition of ad¬ 
renalin to diluted human venous blood 
caused an increase in the intensity of the 
oxyhemoglobin absorption bands. Kariya 
and Tauska (Jour. Tokyo Med. Assoc., 
vol. xxvi. No. 20, 1913) had already 
noticed in a study of hemolysis, that ad¬ 
renalin acted as hemoglobin when fixed 
from the red corpuscles. C. E. de M. S.] 

This interpretation explains the phe¬ 
nomena that attend the use of adrenal 
extracts, adrenalin, etc., in therapeutic 
doses. The rise of temperature noted 
by Morel, Lepine and the concomitant 
rise of temperature and increased me¬ 
tabolism noted by Oliver and Schafer 
are due to increased oxidation. It ex¬ 
plains also the rise of a low blood-pres¬ 
sure, since increased metabolic activity 
—excited directly by the adrenal prin¬ 
ciple besides that due to general 
oxidation—of the muscular coats of 
vessels is manifested by contraction, 
and, therefore, by elevation of the 
blood-pressure. The increased power 
of the heart is the obvious outcome of 
increased metabolism in the myocar¬ 
dium, precisely as it is in the vascular 
muscles, while the slowing of its ac¬ 
tion is due to the greater diastolic ex¬ 
pansion that attends increased func¬ 
tional vigor and the greater resistance 
the blood-column offers as a result of 
the increased blood-pressure. 

The same process explains the phe¬ 
nomena produced by adrenal extract¬ 
ives which appear quite discordant 
from its more familiar effects on the 
blood-pressure, the heart, etc. They 
produce arteriosclerosis by causing ex¬ 
cessive contraction of the vasa vaso- 
rum, from which the arterioles receive 


ANIMAL EXTRACTS (SAJOUS). 


743 


their blood. The walls of the arteries 
these minute vessels nourish being 
partly or completely deprived of blood, 
they degenerate, and sclerosis follows. 
Glycosuria' is also the result of excess¬ 
ive metabolism; the pancreas, as are 
all other organs, being rendered over- 
active, its ferments are secreted in ex¬ 
cess. Amylopsin being one of these, 
the hepatic glycogen is converted into 
sugar in quantities exceeding the needs 
of the tissues, and the unused sugar is 
eliminated by the kidneys. Increased 
metabolism likewise explains the ab¬ 
normal activity of the lachrymal and 
salivary glands. 

Finally, the antagonistic effects of 
these agents are accounted for by the 
fact that, while the intestinal vessels 
are contracted through the excessive 
metabolic activity produced in their 
muscular coats, the intestines them¬ 
selves are relaxed because the volume 
of blood supplied to them is reduced by 
the undue constriction of their vessels. 

[The participation of the adrenal secre¬ 
tion in this phenomenon is shown by the 
fact that the supposed inhibitory action of 
the sympathetic on intestinal movements 
(which, as I have shown in “Internal Se¬ 
cretions,” is merely an experimental phe¬ 
nomenon brought about by excessive con¬ 
striction of the intestinal vessels) is offset 
by severing the nerves to the adrenals. 
This fact, first observed by Jacobi (Arch, 
f. exper. Pathol., Bd. xxix, S. 171, 1892), 
proves, from my viewpoint, that two 
sources of vasoconstriction (manifested by 
elevation of the blood-pressure) must al¬ 
ways be taken into account: (1) that due 
to vasomotor nerves, and (2) that due to 
increased activity of the adrenals. It is by 
producing a similar constriction of the 
arterioles that opium and its analgesic 
alkaloids cause constipation and relieve 
pain—according to my views. C. E. 
DE M. S.] 

Although the contention of physiol¬ 
ogists that the adrenals do not destroy 


poisons through their secretion, as be¬ 
lieved by Abelous and Langlois is war¬ 
ranted, the fact remains that in the 
light of my views the adrenals in¬ 
directly and in conjunction with other 
substances, take part in immuniz¬ 
ing processes. We have seen under 
the heading “Adrenals, Diseases of,” 
the striking influence of adrenalin in 
terminal hypoadrenia. This is un¬ 
doubtedly due in part to the influence 
of the adrenal principle upon general 
oxidation; this function taking part in 
all protective functions, while enhanc¬ 
ing the formation of antigens. 

The writer conducted experiments 
which tended to show that one of the 
functions of the adrenal glands was 
to assist by means of their internal 
secretion in counteracting pathological 
processes or products which might tend 
to produce an abnormal constriction of 
the bronchioles. D. E. Jackson (Jour. 
Pharmacol. and Exper. Therap., 
Sept., 1912). 

Adrenalin prevents absorption of 
poisons, in poisoning by non-corros¬ 
ive substances such as cyanide, 
strychnine, and aconite, and thus per¬ 
mits of the stomach being emptied or 
a suitable antidote administered. It 
should be given at once, followed by 
the antidote or the stomach-pump. 
Another small dose may be given to 
prevent absorption of any remaining 
poison. J. L. Jona (Brit. Med. Jour., 
Feb. 8, 1913). 

Experiments including the use of 
violent cardiac poisons, anagyrine 
and nicotine, showed that after the 
destruction of all central vasomotor 
connections, effects which could only 
be attributed to the adrenals. We 
must, therefore, recognize two classes 
of cardiac stimulants: those which 
act through the nervous system and 
those which act through the adrenals. 
This he regards as a new fact in our 
knowledge of the role of the ductless 
glands in their relations to poisons. 
Gley (C.-r. de Ih^cademie des Sci¬ 
ences, June 29, 1914). 


744 


ANIMAL EXTRACTS (SAJOUS). 


[Nothing of the above is new. I pointed 
out in 1903-1907 (Internal Secretions) 
that it was through the adrenals that digi¬ 
talis and other cardiants produced their 
tonic effects, and not as generally taught 
even now, by a direct action of the drug 
on the heart-muscle—an absurdity. I 
also urge that the toxic phenomena ob¬ 
served by Albanese, Langlois and others 
should be attributed to the participation 
of the adrenal secretion in a general im¬ 
munizing function. It is not as “antigen” 
that it acts, however, as believed by Hal- 
pern. C. E. de M. S.] 

Intraperitoneal injections of ex¬ 
tracts of guinea-pig adrenals, bring 
about in some rabbits the formation 
of substances which exhibit a vaso¬ 
dilator property in frogs. The writer 
deems it justifiable to consider these 
substances as antibodies with ad- 
Tenalin as an antigen. Halpern 
(Archiv. f. exper. Pathol, u. Pharm., 
Oct., 1913). 

On the basis of extensive clinical 
experience the writer recommends 
that Voo grain (0.001 Gm.) of ad¬ 
renalin be administered by hypo- 
dermoclysis in ^ or 1 pint (250 or 500 
c.c.) of saline solution in general in¬ 
fections. Being absorbed slowly, its 
action is sustained. Josue (Paris 
Med., Dec. 4, 1915). 

Physiologists are now teaching that 
the adrenal products inhibit the func¬ 
tions of the stomach, but this effect is 
only observed in animals when doses 
which are not used in man are admin¬ 
istered. 

Extracts of suprarenal gland vigor¬ 
ously inhibit gastric secretion. These 
extracts all contain more or less ad¬ 
renalin and, therefore, it is presum¬ 
able that their effect is produced by 
intensification of the inhibitory func¬ 
tion which is ascribed to the (gas¬ 
tric) sympathetic. Adrenalin is not 
as active a gastric inhibitor as supra¬ 
renal proteins obtained from extracts 
of the whole gland. These supra¬ 
renal nucleoproteins contain only 
traces of epinephrin. Extracts of the 
pituitary gland also inhibit gastric 


secretion, but only about, one-half as 
vigorously as do extracts of the sup¬ 
rarenal. Rogers, Ablahadian and 
Cornell (Amer. Jour, of Physiol., 
Feb. 1, 1919). 

Practical experience in many cases 
has shown that far from inhibiting the 
gastrointestinal canal, adrenalin pro¬ 
motes, even when given a long time, its 
functional activity. 

The soft and elastic arteries in chil¬ 
dren and the integrity of the cardio¬ 
vascular and other systems render 
adrenalin peculiarly effectual in pedi¬ 
atrics. It seems to have a general 
tonic and an antitoxic action as well 
as its direct vasoconstricting effect. 
Except in very urgent conditions, ad¬ 
ministration by the mouth is prefer¬ 
able. This is harmless while it avoids 
abrupt changes in the circulation. 
Its action is more protracted by the 
mouth, and it seems to stimulate the 
centers, possibly by way of the sym¬ 
pathetic system. The dose is from 
10 to 30 drops of the 1 to 1000 solu¬ 
tion. A. Galvani (Rivista di Clin. 
Pediat., May, 1918). 

The writer has obtained good re¬ 
sults in dyspeptics with gastric atony 
by prescribing 8 to 10 drops of 1: 1000 
adrenalin, solution 1 hour before each 
of the 2 main meals, lunch and din¬ 
ner. The results consisted in a 
diminution or disappearance of post¬ 
prandial discomfort or sensation of 
weight, a diminution of splashing 
sounds, and cessation of pain. Pron 
(Presse med., June 10, 1918). 

Physiology of Local Action.—The 
local application of an adrenal prin¬ 
ciple, adrenalin, epinephrin, etc., causes 
such marked contraction of the vessels 
that their lumina, when applied over 
small vessels, may become obliterated, 
thus arresting totally the flow of blood. 
The tissues become very pale, there¬ 
fore, and even blanched. These effects, 
however, are of short duration. Mu¬ 
cous membranes are similarly affected; 


ANIMAL EXTRACTS (SAJOUS). 


745 


hence, the frequent use of adrenal ex¬ 
tractives on the nasal mucosa and the 
conjunctiva. The constrictive effect on 
the blood-vessels is due to a direct ac¬ 
tion on their muscular elements; ap¬ 
plied to the eye, adrenal extractives 
also produce contraction of its muscles. 
Hence, the dilatation of the pupil, the 
wide separation of the eyelids, and ap¬ 
parent protrusion of the eyeball. From 
my viewpoint, the contraction of the 
vessels produced by adrenalin and the 
resultant blanching are due to the in¬ 
creased metabolic activity it awakens 
temporarily in the vascular and other 
tissues to which it is applied. 

[The process does not differ from that 
which obtains in the blood. It is that of 
exaggerated oxidation in which the adren¬ 
alin, as I have pointed out, plays the part 
of a catalyzer. Poehl found that the ad¬ 
renal active principle was endowed with 
catalytic properties. This enables it to 
activate greatly the process of oxidation 
without being itself rapidly consumed— 
its action recalling that of a ferment. 
Jolles showed, moreover, that the catalytic 
activity of a given volume of blood cor¬ 
responded with the number of red cor¬ 
puscles it contained. These corpuscles 
being the carriers of hemoglobin, which, 
in turn, contains the adrenal principle, as 
I have shown, adrenalin, when applied to 
the tissues, acts as if a large amount of 
oxyhemoglobin had been concentrated 
upon it. C. E. DE M. S.] 

A simple intratracheal injection of 
a solution of adrenalin in a normally 
breathing rabbit was found by the 
writers to penetrate within a few 
seconds to the alveoli, chiefly those 
of the left lower lobe; absorption was 
rapid and well maintained, and the 
procedure could be repeated effect¬ 
ively a number of times. Absorption 
of adrenalin from the lung could also 
be obtained at a time when double 
the dose given intramuscularly ex¬ 
erted no blood-pressure effect what¬ 
ever; it continued also after the de¬ 
velopment of pulmonary edema. 


Auer and Gates (Jour. Exper. Med., 
June, 1916). 

It has been taught that adrenalin 
produced an increase in blood-pres¬ 
sure, but if there was one thing ad¬ 
renalin does not do it is that. Ad¬ 
renalin produces a fall in blood-pres¬ 
sure generally, though not always. 
In the Officers’ Reserve Corps at 
riattsburg the speaker tested many 
young men in the pink of condition 
with adrenalin. Within half an hour 
practically all had a fall in blood-pres¬ 
sure. That corresponded with the 
latest physiological laboratory find¬ 
ings. Adrenalin does not produce 
constriction of all the blood-vessels, 
but a constriction of the blood-ves¬ 
sels of the abdominal cavity, and dila¬ 
tion of the muscles of the thigh, 
whereas a larger dose produces con¬ 
striction of the blood-vessels of the 
skin covering the thigh. If the con¬ 
strictors overcome the dilators, there 
is rise in the blood-pressure. Walter 
Timme (N. Y, Phys. Assoc.; N. Y. 
Med. Jour., Feb. 15, 1919). 

PREPARATIONS AND DOSE.— 

The preparations most generally used 
are the dried adrenal gland, the supra- 
rencdiim stccum of the 1915 U. S. P., 
available in tablets or powder, the aver¬ 
age dose of which is 4 grains (0.26 
Gm.), and the active principle epi¬ 
ne phrin, now generally accepted as the 
official name for proprietary prepara¬ 
tions, including adrenalin. 

A synthetic epinephrin has also been 
available, but there is no ground upon 
which it should be given preference 
over the active principle obtained from 
the adrenals. As shown by Shultz, 
Cushny, and others, all synthetic pro¬ 
ducts are about one-half the strength 
of the natural. 

The solution of epinephrin available 
is uniformly of 1; 1000, the doses of 
which are: By the month, 10 to 30 
minims (0.6 to 1.8 c.c.) ; intramus¬ 
cularly or hypodermically, if the region 


746 


ANIMAL EXTRACTS (SAJOUS). 


is massaged, 3 to 15 minims (0.18 to 
0.9 C.C.), always in free dilution with 
saline solution. Intravenously, it should 
only be given drop by. drop in large 
dilution with saline solution, the latter 
being used as in hypodermoclysis. The 
use of strong solutions of 1: 1000 solu¬ 
tion intravenously is always fraught 
with considerable danger. Rectally it 
may also be used freely diluted. 

Uterine injections are dangerous 
unless the solution be very weak. 
The vaginal portion of the uterus 
can be rendered anemic effectually 
and safely by injection of only 10 
c.c. (2l4 drams) of 200 c.c. (6l4 
ounces) of salt solution containing 
merely 1 c.c. (16 minims) of the 1 
per thousand solution of suprarenin 
—there is no need to use a stronger 
concentration. Neu (Zentralbl. f. 
GynM<., July 24, 1909). 

Two fatal cases due to the use of 
suprarenin injected into the cervix 
for operative purposes. The writer 
uses a very weak solution injected in 
, considerable amount. It is not the 
amount of the drug or of the solu¬ 
tion used, but the concentration of 
the solution, that does harm. A large 
amount of a weak solution can be 
used without danger, while a small 
amount of a strong solution will be 
fatal. Braun (Zeit. f. Gyn., July 24, 
1909). . 

As I pointed out in 1907, it is very 
doubtful whether epinephrin, adren¬ 
alin, or any of the adrenal active prin¬ 
ciples are physiologically active in any 
but hypoadrenic or zoeak individuals. 
This I attribute to the fact that gas¬ 
tric secretions give the oxidase reac¬ 
tions (guaiac, etc.), thus showing that 
they can oxidize them before they 
reach the circulation at all, and are 
thus deprived of their physiological 
properties. In hypoadrenic subjects, 
however, even the oxidized product 
(oxyhemoglobin) is taken up from the 
intestinal canal and assimilated. 


Adrenalin injected subcutaneously 
or into the peritoneum in laboratory 
animals has a marked toxic action 
and no adrenalin appears in the urine. 
On the other hand, 20 times this 
dosage and more, given by the 
mouth, causes no signs of toxic 
action, while considerable amounts of 
adrenalin are eliminated in the urine. 
The author thinks that under the in¬ 
fluence of the digestive juice and of 
the mucosa the adrenalin becomes 
bound in some way which deprives 
it of its physiological and toxic 
properties. Falta (Wiener klin. 
Woch., Dec. 23, 1909). 

This does not apply to the dried 
gland, probably because the active prin¬ 
ciple is bound up in organic combina¬ 
tion. S. Solis-Cohen found, more¬ 
over, that, by masticating the dried 
gland without swallowing it, the 
physiological effects manifested them¬ 
selves. 

If for some reason or other injections 
are impracticable the same dose of the 
1: 1000 solution on a lump of sugar, 
inserted between the cheek and gums, 
as practised by Rolleston, or adrenalin 
tablets, containing %o gram (1 mg.), 
placed under the tongue, will serve the 
same purpose though somewhat more 
slowly. The active principle proper, 
is absorbed from the colon, especially 
when administered with saline solu¬ 
tion as previously stated. 

At the suggestion of Sollmann, the 
writer confirmed these effects by a 
series of experimental investigations. 
The effects were often found to ap¬ 
proach and sometimes to be parallel 
with those produced by rapid intra¬ 
venous injection, owing, doubtless, to 
the very great vascularity of the 
region. The injected material, in 
fact, was found at times to pass di¬ 
rectly into the venous circulation, as 
shown experimentally. The adminis¬ 
tration of adrenalin in this manner 
clinically could possibly be of serious 


ANIMAL EXTRACTS (SAJOUS). 


747 


moment, such as causing a sudden 
rise of blood-pressure in cardiovas¬ 
cular disease, arteriosclerosis, etc. 
In conditions of circulatory collapse 
necessitating rapid stimulation, the 
injection of adrenalin into the sub¬ 
mucosa of the nasal septum, or tur- 
binals might be of much value. J. D. 
Pilcher (Jour. Amer. Med. Assoc., 
July 18, 1914). 

Epinephrin, i.e., adrenalin, is also 
conveniently put up as an inhal¬ 
ant, ointment, and suppositories, the 
strength being also 1: 1000 in neutral 
oil, petrolatum, or oil of theobroma in 
the order of the preparations named, 
and some mild antiseptic to preserve 
the latter. • 

Contraindications.—Fridericia (Ugeskrift 
f. Laeger, Dec. 9, 1915) enumerates the 
contraindications against subcutaneous in¬ 
jections of adrenalin. He found in litera¬ 
ture 5 deaths following injections. In 1 
of these a large dose (0.6 Gm.—10 grains) 
had been injected into a vein in a much 
debilitated patient with infarction of the 
lungs, granular nephritis and arterioscle¬ 
rosis. In all the others the epinephrin 
had been injected into the muscle of the 
uterine cervix while the patients were 
under the influence of chloroform. He 
has also found 2 deaths on record after 
subcutaneous injection of adrenalin, but 
these were in infants, only months old. 
A number of clinicians have reported un¬ 
favorable experiences with subcutaneous 
injections of adrenalin in cases of heart 
or valvular defects and nephritis with high 
blood-pressure. On the other hand, testi¬ 
mony is constantly accumulating as to the 
value of adrenalin in sudden heart weak¬ 
ness in the course of acute infectious dis¬ 
eases. It is harmful where signs of a val¬ 
vular defect or hypertrophy of the left heart 
exclude bronchial asthma. With cardiac 
asthma there is no expectoration or 
merely reddish foamy masses. Fine moist 
rales may be heard with cardiac asthma 
while with asthma of the bronchial type, 
there are rhonchi. 

UNTOWARD EFFECTS.—In the 

frog toxic doses produce a temporary 


paresis, the muscles acquiring marked 
rigidity. This is ascribed by some to 
poisoning of the spinal cord, by others 
to a direct action on the muscles. In 
mammals large doses given subcuta¬ 
neously cause excitement, tremor and 
vomiting, paralysis beginning at the 
posterior extremities, polyuria, and 
dyspnea, death ocurring either through 
respiratory failure or cardiac arrest. 
In the cat, however, which bears larger 
doses than other animals, the respira¬ 
tion ceases, as a rule, before the heart’s 
action is arrested. This is due to pul¬ 
monary edema, according to some 
authors and to paralysis of the res¬ 
piratory centers, according to others. 
When the poison is injected into a 
vein the morbid effects are preceded 
by a very rapid and marked rise of the 
blood-pressure. 

Man is more susceptible to the action 
of adrenalin than animals. While a 
subcutaneous injection of 1 dram (4 
c.c.) of a 1:1000 solution will hardly 
affect a rabbit, one-third of that quan¬ 
tity has produced untoward effects in 
normal as well as in tuberculous sub¬ 
jects (Souques and Morel), e.g., ver¬ 
tigo, nausea, vomiting, severe pain un¬ 
der the sternum similar to that of 
angina pectoris, and a feeling of con¬ 
striction about the chest, a rapid pulse, 
dyspnea, cold sweats, and coldness of 
the extremities. 

. In a case of pneumonia in a man of 
65 years, injected subcutaneously 5 
minims (0.3 c.c.) of 1:1000 solution 
adrenalin. About a minute after the 
drug was given, the patient became 
restless, dyspneic, facies blanched, 
eyes fixed, and complained of a con¬ 
striction sensation around the body 
on the level with the heart. His 
pulse became almost imperceptible 
and thready. The condition re¬ 
sembled an attack of angina pectoris. 
An injection of an oil solution of 3 


748 


ANIMAL EXTRACTS (SAJOUS). 


grains (0.2 Gm.) of camphor was im¬ 
mediately given, which acted with re¬ 
markable readiness in combating the 
attack. L. J. Friedman (Med. Sum¬ 
mary, Aug., 1915). 

[This is because he failed to dilute suffi¬ 
ciently the dose administered. C. E. 
DE M. S.] 

Intoxication may also follow the use 
of adrenalin when injected into cav¬ 
ities, such as the vagina, the rectum, 
the urethra, when the mucous mem¬ 
brane is abraded, lacerated, or denuded, 
thus rendering its absorption possible. 
The uterus and urethra appear to be 
especially sensitive. 

Case of a man aged 26 weighing 
190 pounds, heart and lungs normal, 
in whom, to arrest bleeding caused 
by manipulation of the urethra to 
render a stricture passable, 10 minims 
of a 1:1000 solution of suprarenal 
principle were injected through an 
Ultzman instillator. The patient im¬ 
mediately complained of pain in the 
stomach, and a condition of profound 
shock supervened. He complained of 
air-hunger, vomited, and lapsed into 
syncope. As the pulse became slower 
and finally disappeared, and death 
seemed imminent, Yso grain of strych¬ 
nine and Hoo grain of nitroglycerin 
were given hypodermically. In ten 
minutes the radial pulse began to re¬ 
turn, and within an hour the patient 
left the office unassisted. Next day 
progressive dilatation of the stricture 
was practised without the aid of the 
adrenal preparation. Link (Central 
States Med. Monitor, Sept., 1907). 

The prolonged use of adrenal prepa¬ 
rations may induce chronic adrenalism, 
manifested by marked cardiac disor¬ 
ders, especially of the myocardium; 
dyspnea after slight exertion, tachy¬ 
cardia, high blood-pressure, polyuria, 
icteric staining of the conjunctiva, and 
marked increase in weight. 

Case of a man who during one year 
and nine months applied daily to the 
conjunctiva, as a treatment for con¬ 


junctivitis, a solution of adrenalin 
chloride. Palpitations, with marked 
increase of the arterial tension, car¬ 
diac dyspnea on exertion, and poly¬ 
urea, were followed by a yellowish 
tinge of the conjunctiva such as that 
observed in jaundice. A curious 
feature of the case was that the pa¬ 
tient gained in weight rapidly. Cessa¬ 
tion of the instillations and regula¬ 
tion of the diet caused a gradual 
retrogression of these symptoms, but 
there remained some cardiac weak¬ 
ness. K. Feiler (Med. Klinik, May 
17, 1908). 

The writers observed 10 and 20 days 
after an injection in dogs, the charac¬ 
teristic phenomena of anaphylaxis on 
injecting another dose of %5 grain 
(0.001 Gm.) of adrenalin and a weak 
dose of thionin, normally inactive. 
The usual primary rise of pressure 
and the secondary depression were 
observed. Gautrelet and Briault (Soc. 
de Biol., July 12, 1913). 

Local applications are sometimes fol¬ 
lowed by untoward effects in the tissues 
to which epinephrin solutions are ap¬ 
plied. Repeated applications, especially 
with the atomizer, of anything but 
weak solutions (1: 10,000) to the nasal 
cavities or pharynx may give rise to 
edema of the nasal mucosa, the uvula, 
tonsils, or'pillars of the fauces. This 
is ascribed by most writers to “violent 
vasomotor constriction of the blood¬ 
vessels” and the resulting “venous stag¬ 
nation.” In some instances they cause 
persistent sneezing and acute coryza 
accompanied at times by severe pain in 
the upper portion of the nasal cavities. 

Case of a man aged 39, of good 
habits and good health, except for his 
periodic attacks of hay fever, who 
was advised by a lay friend to use 
one of the well-known preparations 
of the suprarenal gland, and supplied 
himself with the remedy and an ato¬ 
mizer in the summer of 1905. He 
used it several tim.es a day during his 
attack. 


ANIMAL EXTRACTS (SAJOUS). 


749 


When the hay fever subsided he 
noticed that there was a fullness in 
his nose that did not disappear, but, 
on the contrary, became more 
marked. He was treated by his 
physician for a time without relief, 
and then sought the aid of a rhinol- 
ogist. The condition refused to yield 
to any form of treatment, and, symp¬ 
toms of Eustachian congestion super¬ 
vening, it became necessary to re¬ 
move portions of both middle tur¬ 
binates. After a long course of treat¬ 
ment he went to his home improved, 
but bearing traces of the condition 
with him. Two other very similar 
cases witnessed. B. H. Potts (Jour. 
Amer. Med. Assoc., Oct. 13, 1906). 

Adrenalin, when applied to the 
gums on cotton-wool—whether to 
stop bleeding or, as has been recom¬ 
mended in the preparation of cavi¬ 
ties, to control the saliva exuding 
from the mucous glands at the neck 
of the teeth—should be used with 
great caution. The cotton-wool with 
the adrenalin solution should be thor¬ 
oughly squeezed to remove excess 
before applying. 

The writer had occasion to witness 
recently a distinct case of adrenalin 
poisoning in which it had been used 
to stop bleeding. Evidently in this 
case the adrenalin had been applied 
freely, and, on pressure being used to 
the pad of cotton-wool, a few drops 
of the excess adrenalin had been 
squeezed out. The symptoms were 
alarming, being not unlike an epilep¬ 
tic seizure, and the patient remained 
in a collapsed condition for some 
hours after. Anonymous (Chemist 
and Druggist; Prescriber, March, 
1911). 

Some cases have been reported in 
which sloughing and gangrene of the 
mucosa occurred. Elderly subjects 
are prone to this complication, accord¬ 
ing to Neugebauer. Postoperative 
hemorrhages are not infrequently 
noticed after the use of adrenalin, 
owing to relaxation of the severed 
vessels. 


In the larynx, epinephrin solutions 
cause an uncomfortable dryness by 
interfering with the formation of 
lubricating mucous. This is especially 
distressing to singers. In the eye 
their use in scleritis and other dis¬ 
orders may be followed by severe 
iritis. Instillations of a 1: 1000 solu¬ 
tion in the Eustachian tubes have 
given rise to violent pain in the mid¬ 
dle ear, which was renewed whenever 
the remedy was thus administered. 
The use of adrenalin solutions, in 
the form of a spray at least, is con¬ 
traindicated in infections, owing to 
the danger of facilitating the entrance 
of pathogenic germs into the sinuses. 

The role I attribute to the adrenal 
secretion in oxidation, metabolism, and 
nutrition is as applicable to the unto¬ 
ward phenomena as it was to the thera¬ 
peutic action of the drug. Following 
the course of events from start to fin¬ 
ish, we have at first the effects of ex¬ 
cessive metabolism in all tissues: in 
the cerebrospinal system, excitement; 
in the muscles, tremor; in the kidneys, 
polyuria; in the myocardium, violent 
contractions (palpitations); in the 
muscular coats of the vascular system, 
a marked rise of the blood-pressure. 
The latter in turn aggravates the proc¬ 
ess by causing congestion and en¬ 
gorgement of the capillaries (which are 
not, like the arteries, provided with a 
muscular coat) of all organs, including 
the lungs, causing edema of these struc¬ 
tures and dyspnea. As the contraction 
of the arteries proceeds, the aorta has 
to bear the brunt of the centrifugal 
pressure, giving rise to marked sub- 
sternal pain. When it becomes such 
that the arterioles obstruct the circu¬ 
lation the lethal phenomena are initi¬ 
ated: the pulmonary circulation being 
impeded, oxygenation fails to occur, 


750 


ANIMAL EXTRACTS (SAJOUS). 


asphyxia follows, and, the myocardium 
receiving too little blood to sustain its 
contractile power, the heart, already 
hampered by the pulmonary congestion, 
ceases to beat. 

In chronic adrenalism the same in¬ 
terpretation obtains, the cardiac phe¬ 
nomena being ascribable mainly to the 
extra work imposed upon the heart by 
the resistance of the general vascular 
tension. The gain in weight is a nor¬ 
mal result of increased metabolic ac¬ 
tivity, i.e., overnutrition. 

After local applications the morbid 
effects are all the result of the action of 
the adrenal principle upon the vessels. 

The dryness produced by solutions 
sprayed into the larynx is due to defi¬ 
ciency of blood supplied to the acini 
and the resulting inhibition of their 
function. If this is kept up by repeated 
applications, the tissues, no longer 
nourished, may slough off, as has been 
noticed in the upper respiratory tract 
of aged subjects, The edema observed 
in this location is not active, as it is in 
the lungs, but passive, i.e., due to ex¬ 
aggerated relaxation of the vessels af¬ 
ter the intense constriction to which 
the drug had subjected them. This 
applies equally well to postoperative 
hemorrhage, and to the severe pain 
(due to passive congestion) in the 
middle ear after instillations in the 
Eustachian orifice. 

THERAPEUTICS.—Addison’s 
Disease.—Textbooks of practice and 
therapeutics now teach pretty gen¬ 
erally that adrenal preparations are of 
value in Addison’s disease. A personal 
study of the literature of the subject 
showed that out of 120 cases treated by 
adrenal preparations 25 had been suffi¬ 
ciently benefited to be restored to 
health—as far, at least, as the loss of 


adrenal tissue incurred through the 
local morbid process would permit. 

The one great factor in the treatment 
of this affection by means of adrenal 
extractives is to drop their empirical 
use, and it is only (and this applies to 
the use of any disease) when the im¬ 
portance of this fact will have been 
thoroughly grasped that the proportion 
of recoveries will be materially in¬ 
creased. Empiricism here may entail 
death. 

[E. W. Adams (Practitioner, Oct., 1903) 
refers to a group of 7 cases found by him 
in literature “in which alarming or fatal re¬ 
sults were presumably or possibly due to 
the treatment.” He mentions, for instance, 

2 cases reported by a prominent clinician 
treated with “suprarenal gland extract.” 
The chart notes of the cases include the la¬ 
conic words: “Alarming collapse. One of 
the cases began to improve markedly when 
the extract was stopped.” In the original 
paper reference is made to another case 
treated by suprarenal extract in which 
“similar collapse was noted.” The dose was 
not mentioned. Such cases are apt to be 
regarded as examples of the sudden death 
sometimes observed in Addison’s disease, to 
which Addison himself, Dieulafoy, Ander¬ 
son, Bradbury, and others have called atten¬ 
tion; but this explanation does not hold. 
Guiol (Bull, de la Soc. rhedico-chir. du Var., 
Dec., 1906), having observed similar signs of 
intoxication and collapse, tried the “remedy”’ 
in a normal subject and obtained the same 
morbid phenomena. Here, again, we are 
dealing with fatalities which occurred when 
the physiological functions of the organs, 
and, therefore, their mode of action as a 
therapeutic agent, were but slightly known. 

C. E. DE M. S.] 

The salient guides in the use of these 
preparations are the low temperature, 
which denotes deficient oxidation and 
metabolism, and the weak pulse, which 
points to a low vascular tension and 
inadequate cardiac dynamism. Im¬ 
provement of a given case is indicated 
by a gradual resumption of normal 


ANIMAL EXTRACTS (SAJOUS). 


751 


conditions in these two directions, and 
by the return of bodily vigor, with 
more or less fading of the pigmenta¬ 
tion. As a rule, the more these various 
morbid phenomena are marked, the 
larger will be the initial dose required. 
In other words, marked hypothermia, 
a very feeble pulse, advanced bronzing, 
and great debility will indicate that a 
mere vestige of both adrenals is still 
active; the dose indicated, then, is that 
which will supply enough additional 
principle to raise the temperature and 
the blood-pressure to normal, but not 
beyond. A study of the 120 above- 
mentioned cases has shown that 3 
grains (0.2 Gm.) of the desiccated 
gland three times daily was the most 
satisfactory dose to start with. If this 
fails to raise the temperature and the 
pulse tension or improve the case, the 
dose should be increased by 1 grain 
per day until it does, the case being 
watched closely. As soon as the nor¬ 
mal temperature is reached, the dose 
should no longer be increased, unless a 
tendency to recurrence of the hypo¬ 
thermia (gradually as the adrenals are 
being destroyed by the local morbid 
process) should render it necessary. In 
less advanced cases the initial doses 
should be correspondingly small, 2 or 
even 1 grain of the extract being ad¬ 
ministered three times daily, the dose 
decreasing in proportion as the disease 
is less advanced. 

Can we expect a cure from adrenal 
preparations? In most cases of Addi¬ 
son’s disease the local process is tuber¬ 
cular—often limited to the adrenals. A 
number of examples suggest, however, 
that the tubercular process itself was 
benefited, and even cured, by the use 
of adrenal extract. It is always well, 
however, to treat simultaneously the 
tuberculosis on general lines. 


The writer observed a case due to 
adrenal tuberculosis which showed 
that marked increase in vitality and 
strength may be secured by supra¬ 
renal extract without as great an in¬ 
crease in the blood-pressure as would 
be expected. Judson Daland (Endo¬ 
crinology, July-Sept., 1918). 

A number of cases are on record in 
which, after apparent recovery, the 
cases died suddenly soon after ceasing 
the use of adrenal preparations. It is 
evident that even the possibility of 
curing the morbid process in the adre¬ 
nals does not replace the destroyed 
adrenal tissue. It is here that grafting 
would be of curative value, but only 
provided small fragments of adrenal 
tissue be inserted, and gradually in¬ 
creased in number until the tempera¬ 
ture and pulse indicate that compensa¬ 
tion for the functionless areas in the 
adrenals has been increased 

The 120 cases analyzed showed also, 
and my own experience has further 
demonstrated, that what is generally 
known as “adrenal extract,” but which, 
in reality, is the desiccated adrenal 
gland (the glandidcc siiprarcnales siccce 
of the U. S. P.), is by far the most sat¬ 
isfactory agent to use. Injections of 
adrenal fluidextracts are exceedingly 
painful—a fact which compromises the 
issue by introducing the element of 
shock—while the active principle, epi- 
nephrin, adrenalin, etc., sometimes fails 
altogether to act. 

See, also Addison's Disease, Treat¬ 
ment OF, this volume. 

Shock, Collapse, and Surgical Dis¬ 
eases.—This is another condition in 
which adrenal preparations show 
prominently their influence on metabo¬ 
lism. The function I ascribe to the 
adrenal secretion (to take up the oxy¬ 
gen of the air, and be carried to the 
tissues where its active principle aug- 


752 


ANIMAL EXTRACTS (SAJOUS). 


merits greatly the activity of this gas) 
involves the conclusion that it is a 
prominent factor in the sustenance of 
the body heat, a fact demonstrated by 
Reichert, Lepine, Morel, and others. 
Now, Kinnaman, in a comprehensive 
study of the temperature relationship 
to shock, concluded that as shock in¬ 
creased in severity the most uniform 
progressive factor was the fall in tem¬ 
perature. He states that “in one series 
[of cases] the fall in temperature was 
the sole cause of shock!” The results 
of Crile with adrenalin in salt solution 
given very slowly and gradually for a 
considerable time thus find a normal 
explanation in my interpretation of the 
role of the adrenal secretion. He sup¬ 
plied the organism precisely with the 
substance which sustains the vital proc¬ 
ess in the tissue-cells. Indeed, he re¬ 
suscitated animals in this manner—with 
simultaneous artificial respiration—fif¬ 
teen minutes after all signs of life had 
ceased, and was able to keep a decap¬ 
itated dog alive over ten hours by this 
same procedure. That it was because 
the adrenal secretion is able to sustain 
tissue metabolism, i.e., the vital process 
itself, that such results were obtained 
seems self-evident. 

In the great war, most of the 
wounded arrived in a more or less 
pronounced state of shock and needed 
some restorative before being oper¬ 
ated upon. The writer has used ad¬ 
renalin in saline solution with good 
results. A half milligram (M 20 grain) 
of adrenalin is mixed with 500 Gm. 

(1 pint) of saline solution and every 
patient in shock is injected with 500 
6m. (1 pint) of this mixture. Imme¬ 
diately after operation a second in¬ 
jection is made and 2 injections per 
day are given for several days; gen¬ 
erally, however, it is not needed after 
2 or 3 days. The effects are marked 
increase in blood-pressure and a 
more ample pulse as well as improve¬ 


ment in the general condition. Du¬ 
pont (Arch, de med. et pharm. mil., 
Ixiv, 542, 1915). 

The rate of output of adrenalin in 
dogs and cats, after the blood-pres¬ 
sure had been permanently lowered 
by exposure and manipulation of the 
intestines, by partial occlusion of the 
inferior vena cava, by hemorrhage 
and by “peptone” injection, was 
found by the writers, to be the same 
as before the lowering of the blood- 
pressure, within the limits of error of 
the methods used for assaying the 
epinephrin. A marked increase in the 
rate of output of adrenalin was pro¬ 
duced by strychnine. Stewart and 
Rogoff (Amer. Jour. Physiol., Feb. 1, 
1919). 

This applies not only to shock, but 
also to surgical heart-failure, collapse 
from hemorrhage, asphyxia, and sub¬ 
mersion. The adrenal principle (su- 
prarenalin, adrenalin, etc.) promotes 
energetically, as a catalyzer and con¬ 
stituent of the hemoglobin, the intake 
of oxygen and its utilization by the tis¬ 
sue-cells, including the muscular ele¬ 
ments of the cardiovascular system, 
and thus causes them to resume their 
vital activity. It should be very slowly 
administered intravenously, 5 minims 
of the 1000 solution to the pint of 
warm (105° F.) saline solution. In 
urgent cases 10 drops of suprarenalin 
or adrenalin in 1 dram of saline solu¬ 
tion can be used instead, and repeated 
at intervals until the heart responds. 
Artificial respiration hastens its effects. 

In collapse from weakness of the 
vasomotor center, such as is liable in 
pneumonia, diphtheria, and perito¬ 
nitis, good results may be obtained 
with a suprarenal preparation in¬ 
jected into a vein, or, diluted with 
salt solution, injected subcutaneously. 
Case of uncomplicated ileus in which 
by this means it proved possible to 
tide the apparently moribund patient 
past the danger stage after two days 


ANIMAL EXTRACTS (SAJOUS). 


753 


of fecal vomiting, and thus permitted 
a successful operation. Heidenhain 
(Deut. Zeit. f. Chir,, April, 1910). 

Research showing that epinephrin 
has no cumulative action. Its action 
only on direct contact. The contin¬ 
ual infusion of a weak solution of 
epinephrin may prove a useful meas¬ 
ure in therapeutics. It is thus pos¬ 
sible to send the solution continu¬ 
ously into a vein and thus keep up 
the blood-pressure permanently while 
this is being done—the effect being 
dependent on the concentration of 
the solution, not on the absolute 
amount of epinephrin infused. Straub 
(Miinch. med. Woch., June 27, 1911). 

During the war the writer in 1 year 
encountered 15 cases of what seemed 
to be Addison’s disease, in men in 
active service, except that it displayed 
a tendency to spontaneous subsid¬ 
ence, even in apparently the gravest 
cases. A few weeks of rest and quiet, 
abstention from meat, and treatment 
with suprarenal extract soon banished 
all the symptoms. In two of the 
cases there was what Loeper has 
described as suprarenal dyspepsia, 
notably improved by epinephrin. 
The symptoms developed in all after 
a period of exhausting fatigue, an in¬ 
fectious disease, or gassing.* The 
asthenia was the most striking symp¬ 
tom, more mental than physical. For 
months the men were incapable of 
reading a paper, writing a letter or 
even answering questions that re¬ 
quired any thought. Improvement in 
this respect was rapid under epi¬ 
nephrin treatment. The blood-pres¬ 
sure was low, but this is common 
among all the men at the front. A 
certain tendency to bronzing of the 
skin was perceptible in all the 15 
cases. 

The suprarenals, after the patient’s 
recovery are left below par, and re¬ 
sumption of active service is ex¬ 
tremely likely to rearouse the old 
trouble, and the next time it might 
prove grave beyond recuperation. 
Carles (Jour de Med. de Bordeaux, 
July, 1918). 


Reference Avas made under “Un¬ 
toward Effects” to the dangers at¬ 
tending the use of the adrenal prin¬ 
ciples in surgery to produce ischemia 
at the seat of operation. Though 
such effects are not often met with, 
the fact remains that they should be 
borne in mind and the principle that 
it is the free dilution of epinephrin, 
adrenalin, etc., that promotes safety. 
Surgical operations can also be per¬ 
formed without loss of blood, except 
from the larger vessels, in almost any 
organ by injecting locally 8 to 10 
minims of a 1: 1000 solution in four 
or five times the same quantity of 
saline solution. Care should be taken 
not to inject too large a dose lest the 
untoward effects described earlier in 
this article occur. Solutions of 1:10,- 
000 or even 1: 100,000 are quite suffi¬ 
cient sometimes to produce a blood¬ 
less field by causing local constriction 
of the blood-vessels. 

Toxemias and Bacterial Infections. 
—This is a recent and important de¬ 
velopment of organotherapy. Abel- 
ous and Langlois, Charrin, Oppen- 
heim, and others have laid stress on 
the antitoxic functions. The process 
through which this protective role 
was carried out by these organs be¬ 
ing admittedly unknown, I submitted 
in 1903 and 1907 (“Internal Secre¬ 
tions”) evidence tending to show that 
the adrenals and thyroid were the 
sources of two substances as promi¬ 
nent agents in the immunizing pro¬ 
cess—the thyroid carrying out, we 
have seen, the role of opsonin (con¬ 
firmed by Fassin, Stepanoff, and 
Marbe), while the adrenal secretion 
acted as amboceptor. While I do 
not regard these two agents as the 
sole participants in the immunizing 


754 


ANIMAL EXTRACTS (SAJOUS). 


process, the fact remains that the ad¬ 
dition of either of them to the blood 
enhances to a certain extent its func¬ 
tional activity. Especially is this the 
case in view of the fact that adrenal 
secretion, as previously stated, serves 
to sustain oxidation and tissue me¬ 
tabolism. By doing so it activates 
the functions of all tissues, including 
those concerned with the production 
of protective substances. The blood 
thus finds itself richer in these sub¬ 
stances and more active as a germi¬ 
cidal and antitoxic agent. 

Infectious diseases constitute the 
principal field in which the adrenalin 
treatment is of service, and the writer 
has employed adrenalin successfully 
in many cases of severe collapse in 
connection with scarlet fever, pneu¬ 
monia, and typhoid fever. He does 
not hesitate to use large doses. He 
invariably administers it by subcu¬ 
taneous injection and has observed 
no after-efifects. Kirchheim (Miinch. 
med. Woch., Dec. 20, 1910). 

Adrenalin, injected intravenously, 
in saline solution, is indicated in the 
treatment of peritonitis, used con¬ 
tinuously. The action of adrenalin- 
on the diseased organism must be 
borne in mind. By using the drug in 
very dilute solution weakened systole 
becomes strengthened and in time 
becomes normal in force. The weak¬ 
ened heart and lowered blood-pres¬ 
sure of peritonitis, also due to a toxic 
substance, indicate the same measure. 
Holzbach (Miinch. med. Woch., May 
23, 1911). 

One c.c. (16 minims) of adrenalin 
injected subcutaneously in acute in¬ 
fections, typhoid, pneumonia, etc., 
was found by the writer to cause a 
sudden rise of pressure with but a 
slight increase of the amplitude of 
the pulse; 0.75 c.c. (12 minims) pro¬ 
duced less rise in pressure but greater 
pulse amplitude both on account of 
increased systolic and lowered dias¬ 
tolic pressure; 0.5 c.c. (8 minims) did 
not apparently cause any constriction 


of the peripheral blood-vessels, but 
by dilating the venous system and 
acting on the nerve mechanism of 
the heart, it improved the venous 
circulation and consequently the 
nutrition of the heart. The large 
doses may be used promptly in 
postoperative shock, collapse, or 
acute poisoning; otherwise the smal¬ 
ler doses are safer and productive of 
better results. S. M. Mansvetova 
(Roussky Vratch, June 21, 1914). 

Epinephrin or adrenalin may be 
used advantageously in infectious 
diseases, but to avoid untoward ef¬ 
fects it is best given well diluted:—10 
to 15 drops of the 1: 1000 solution in 
not less than 1 dram of water, admin¬ 
istered very slowly. If given intrav¬ 
enously it is preferable to administer 
the saline solution as usual, and then 
to introduce the needle of the hypo¬ 
dermic syringe into the rubber pipe, 
injecting a drop of the adrenal active 
principle (preferably supracapsulin 
1: 1000) into the stream of saline 
solution at short intervals. In this 
manner much more adrenal principle 
can be introduced with a minimum 
of danger. 

. The writers relate the following 
cases: Man, aged 44, had recently 
gone through an attack of quinsy, 
after which he suffered from what 
was regarded as lumbago. The next 
symptoms were those of probable 
malignant disease of the left side of 
the neck—a parent lesion and en¬ 
larged regional lymphnodes. He also 
began to emaciate without apparent 
cause, which reinforced the diagnosis 
of malignancy.- It was thought that 
the tumor in the neck was a second¬ 
ary nodule, but no primary growth 
could be detected anywhere. The re¬ 
mainder of the finds of a systematic 
examination were also negative with 
the exception of vascular hypotension. 
Thi.s first drew attention to the ad¬ 
renals and Sergent’s, white line was 
repeatedly obtained. Poultices ap- 


ANIMAL EXTRACTS (SAJOUS). 


755 


plied to the loins brought out a 
brown pigmentation. An injection 
of adrenalin increased the blood-pres¬ 
sure without causing glycosuria. The 
lumbalgia had persisted. The pa¬ 
tient was interned technically for a 
slight bronchitis, but in the hospital 
he rapidly sank and died of adynamia. 
Autopsy revealed a complication of 
affections, the primary growth being 
an ulcer of the base of the tongue 
with numerous metastases, including 
the visible ones of the neck. The 
right adrenal was the seat of a can¬ 
cerous metastasis, while its fellow ap¬ 
peared to be hypertrophied. The 
second patient was a man of 24 years, 
who went through a typhoid fever 
complicated with perforation and 
peritonitis. Owing to the profound 
state of depression, a surgical opera¬ 
tion was out of the question. The 
presence of the white line and low 
blood-pressure showed the condition of 
the adrenal functions. Death was 
preceded by the development of acute 
hemorrhagic diathesis. There was a 
marked anatomical foundation for the 
adrenal insufficiency, but the lesions 
could not be interpreted beyond evi¬ 
dences of degeneration of some sort. 
Such lesions have frequently been 
encountered in death from acute in¬ 
fectious diseases, but the rationale is 
not apparent, although the adrenals 
have evidently lost most of their 
lipoid content. Betchov and Demole 
(Revue med. de la Suisse Romande, 
June, 1918). 

The recognition of the antitoxic 
property of the adrenal active principle 
has recently caused it to be employed 
as an antidote in stiVchnine poison¬ 
ing, a fact pointed out by Abelous 
and Langlois in 1898. These authors 
also found it to oppose the toxicity 
of nicotine, while Oppenheim ob¬ 
tained similar results with phos¬ 
phorus. 

Exner has shown that intraperitoneal 
injections of adrenalin diminish the 
rate of absorption of strychnine intro¬ 


duced into the stomach, and the writer, 
therefore, decided to try whether adren¬ 
alin given by the mouth would exert a 
similar effect. He first found that 
adrenalin could exert its vasocon¬ 
strictor action after the arteriolar, wall 
has been subjected to the action of 
cyanide of potassium, and then studied 
its effects upon rabbits poisoned by the 
cyanide. He was ablq to bring about 
recovery after longer periods than in 
rabbits which had not received adren¬ 
alin. He recommended the following 
procedure for cases of cyanide poison¬ 
ing in man. Adrenalin should be given 
immediately, 9 c.c. (i.e., 3 drams) of the 
1: 1000 solution diluted to 90 c.c. saline 
solution; then Martini and O’Brien’s 
antidote if available. This consists of 
30 c.c. (1 ounce) of a 23 per cent, solu¬ 
tion of ferrous sulphate, 30 c.c. of 5 
per cent, solution of caustic potash, and 
2 Gm. (30 grains) of magnesia. The 
first two solutions should be kept in 
hermetically sealed phials. The three 
substances should be mixed when re¬ 
quired and immediately taken. The 
principle of the method is the forma¬ 
tion of Prussian blue, which is prac¬ 
tically innocuous. The stomach should 
then be washed out and a further dose 
of about 5 c.c. (1^2 drams) of 1:1000 
adrenalin solution diluted to 50 c.c. 
should be given. A brisk saline purge 
is also recommended, to be administered 
soon afterward. J. L. Jona (Intercol. 
Med. Jour, of Austral., July 20, 1909). 

Adrenalin found experimentally to 
counteract the toxic symptoms induced 
by strychnine in the frog. Similarly, 
if adrenalin and strychnine are in¬ 
jected, guinea-pigs will tolerate sev¬ 
eral times the fatal dose of the latter 
drug. The action of adrenalin is 
actually antagonistic and not de¬ 
pendent on vascular contraction, with 
slower absorption, as some authors 
claim, since other poisons are not 
affected in their toxicity. The an¬ 
tagonism is very similar to that 
between atropine and muscarine. 
Falta and Svcovic (Berl. klin. Woch., 
Oct. 25, 1909; Merck’s Archives, Jan., 
1910). 


756 


ANIMAL EXTRACTS (SAJOUS). 


Postoperative Intestinal Atony.— 

To the adrenals seem also to belong 
the credit of offering the opportunity 
to antagonize this disorder. When in 
1903 I submitted the opinion that the 
thyroid secretion enhanced the activ¬ 
ity of the adrenals—a view since sus¬ 
tained by several experimenters—and 
that the adrenal secretion on the 
other hand, influenced the functional 
activity of the pancreas, pituitary 
body, and other organs, the state¬ 
ment created some surprise. This 
feeling died out, however, when, three 
years later. Starling termed hormones 
a group of substances secreted by 
various organs which could enhance 
the functions of other organs. Pre¬ 
cisely as I had previously held, these 
hormones were secreted, according 
to Starling, by the organs which pro¬ 
duced them in the course of their nor¬ 
mal functions, and reached the distant 
structures they influenced through 
the intermediary of the blood. What 
I termed the adrenal system owed 
in great part its functional activity 
to this chemical co-ordination; the 
adrenal secretion being especially 
prominent in the process owing to 
the function I attributed to it, viz., 
to sustain oxidation and metabolism 
as a constituent of the hemoglobin 
molecule. 

Bayliss and Starling termed secretin 
a hormone formed in the intestinal 
mucous membrane under the influence 
of the hydrochloric acid from the 
stomach, which is the chemical ex¬ 
citant of the pancreatic secretion. 
Now, from my viewpoint, this is not 
a specific excitant; I showed in 1907 
(vol. ii, “Internal Secretions,” p. 
861) that it presented several of the 
properties of adrenal extractives. We 


are dealing, therefore, not with a local 
product, but with a component of all 
tissues (being as such what Starling 
has termed a “mamma hormone”), 
and which when present in unusual 
quantities in any organ is capable of 
enhancing correspondingly its func¬ 
tional activity owing to its influence 
on local oxidation and metabolism. 

Another hormone has been ob¬ 
tained from the gastric mucosa by 
Dohon, Marxer, and Zuelzer (Berl. 
klin. Woch., Nu. 46, 1908), which was 
found to enhance intestinal peristal¬ 
sis. But inasmuch as it is (from my 
viewpoint) a ubiquitous component 
of all tissues, and the difficulty of 
collecting it during digestion being 
obvious, search for it elsewhere sug¬ 
gested itself. It was found in ample 
quantities in the spleen—that junk- 
shop in which red corpuscles (which, 
as I suggested in 1903, are the com¬ 
mon carriers of the adrenal principle) 
are broken up along with other cells. 
That the splenic hormone referred to 
is not purely the adrenalin-laden al¬ 
buminous constituent of the hemo¬ 
globin derived from red corpuscles 
is self-evident, since leucocytes with 
their nucleoproteid granulations, 
their trypsin-like cytase, and other 
ferments are also broken up in the 
spleen. The fact remains, however, 
that this splenic hormone specifically 
stimulates intestinal peristalsis to a 
degree so remarkable experimentally 
that it may be readily seen in the ex¬ 
posed intestine of experimental ani¬ 
mals ten to fifteen minutes after an 
intravenous injection. 

The applications of this peristaltic 
hornionei in surgery are mainly in 
those conditions of intestinal paresis 
following operations on the intestine, 
and particularly where purgatives. 


ANIMAL EXTRACTS (SAJOUS). 


757 


castor oil included, bring- on no re¬ 
sults. It is also indicated in all forms 
of stubborn constipation due to intes¬ 
tinal atony. 

Miscellaneous Disorders.—The 
foregoing disorders may be said to rep¬ 
resent those in which adrenal prepara¬ 
tions are more effective than any other 
preparation at our disposal. There are 
several others, however, in which they 
will probably prove of considerable 
value, when sufficient trial of them in 
practice will have warranted a final 
pronouncement. These are:— 

Hemorrhage from the pharyngeal, 
esophageal, gastric, or intestinal mucous 
membrane. Here the mastication of 
adrenal substance or the use of pow¬ 
dered adrenal substance in 5-grain 
capsules arrests the flow, by causing 
active metabolism in the muscular ele¬ 
ments of the arterioles of the mucosa 
and constriction of these vessels. The 
active principle, epinephrin, supracap- 
sulin, etc., has also been given by the 
mouth in 10- to 15- drop doses. 

To avoid hemorrhage during the re¬ 
moval of placental rests after abortion 
the writer exposes the cervix and prac¬ 
tises deep injection of the following 
solution into several points of the cer¬ 
vical tissue,—either 1 c.c. of 1 per cent, 
or 2 c.c. of Vz per cent, cocaine solu¬ 
tion to which 3 drops of 1: 1000 adren¬ 
alin solution has been added. After 
waiting ten minutes, the operation of 
emptying the uterus is practically blood¬ 
less and the organ is firmly contracted, 
though patency of the cervix remains. 
O. Crasser (Zentralbl. f. Gynak., June 
19, 1909). 

The writer has seen within the past 
year 5 cases of vicarious hemorrhage, 
1 of the rectum, from the inner can- 
thus of the nose, etc., in which he pre¬ 
scribed the suprarenal extract—adren¬ 
alin 1: 1000, giving 15 drops every 
three hours until it ceased—and secured 
prompt relief. J. W. Irwin (Med. 
Brief, Aug., 1911). 


Spontaneous recurrent epistaxis is 
usually due to ulceration over capil¬ 
laries or a vessel in the anterior 
nares, but at times it is difficult to 
locate the precise area from which 
the hemorrhage comes. This may be 
overcome by an application of ad¬ 
renalin solution to the anterior por¬ 
tion of the septum. This blanches 
the whole mucosa except at the 
spots which give rise to the bleeding. 
These then stand out clearly against 
the pale surface as red, circular 
areas. W. Lapat (Jour. Amer. Med. 
Assoc., Ixvii, 1159, 1916). 

Asthenic cardiac disorders with dila¬ 
tation of the right ventricle, dyspnea, 
and possibly cyanosis and edema, ow¬ 
ing to the direct action of the adrenal 
principle on the right ventricle and 
improved oxidation and metabolism 
in the cardiovascular muscles and 
the tissues at large. Tablets of from 
% to 1 grain of the desiccated gland 
can be taken after meals. 

Adrenalin caused in the terrapin a 
disappearance or a diminution in the 
tonus waves observed in the sino- 
auricular muscle preparation, and a 
simultaneous increase in the force 
and amplitude of the contraction, and 
in some instances an increase in the 
rate of contraction. When the solu¬ 
tion was strong, the waves ceased al¬ 
most immediately; when a more di¬ 
lute solution was used, only a few 
tonus waves appeared after the addi¬ 
tion of the adrenalin to the Ringer’s 
solution. The length of time re¬ 
quired after an injection of adrenalin, 
before the recurrence of the waves, 
varied directly with the strength of 
the adrenalin solution used. Oxygen 
added to Ringer’s fluid seemed to 
hasten the process of recovery, which 
might be only a matter of hastening 
the oxidation of the adrenalin. Gru¬ 
ber and Markel (Jour, of Pharm. and 
Exper. Therap., Aug., 1918). 

The writer tested the effect of the 
injection of 0.5 c.c. (8 minims) of a 
1:1000 solution of adrenalin in nor¬ 
mal soldiers and in soldiers suffering 


758 


ANIMAL EXTRACTS (SAJOUS). 


from “irritable heart.” In only 1 of 
the 27 control cases was there a sug¬ 
gestion of hypersusceptibility to epi- 
nephrin. In 65 patients the epi- 
nephrin test was positive in 39, doubt¬ 
ful in 6 and negative in 19. The 
most important symptoms of the re¬ 
action were the presence of tremors, 
sweating, flushing, pulsation of peri¬ 
pheral blood-vessels, general nervous¬ 
ness and increase in blood-pressure, 
pulse-rate and depth of respiration. 
Furthermore, the “irritable heart” 
cases showed an increase in basal 
metabolism and in blood sugar more 
marked than in normal individuals. 
The electrocardiogram showed most 
constantly a slight decrease of the 
height of the T-wave., In individual 
cases other abnormalities were seen, 
such as increase of sinus arrhythmia, 
prolongation of P-R interval, partial 
heart block, inversion of the T-wave 
and the production of ventricular ex¬ 
trasystoles. The writer advises the 
use of epinephrin as an aid in the 
diagnosis of “irritable heart.” Pea¬ 
body (Jour. Amer. Med. Assoc., Ixxi, 
1912, 1918). 

Asthma .—To arrest the paroxysms, 
by augmenting the pulmonary and tis¬ 
sue intake of oxygen and the cardio¬ 
vascular propulsion of arterial blood. 
From 5 to 10 minims of the 1:1000 
solution of adrenalin in 1 syringeful of 
saline solution should be injected hypo¬ 
dermically, very slowly, massaging the 
part so as to insure absorption of the 
solution. 

[The effect is so rapidly obtained and 
satisfactory that the patient is sometimes 
entrusted with a syringe and allowed to 
treat himself. But this is a dangerous 
procedure. I have observed, in consultation, 
a death which could undoubtedly be attrib¬ 
uted to this cause. C. E. de M. S.] 

Case in which alarming manifesta¬ 
tions were produced by the hypoder¬ 
mic administration of adrenalin. The 
man became cyanotic and had the 
most severe rigors the writer had 
ever seen; but the asthmatic attack 


was immediately relieved. After sub¬ 
sidence of the rigor the only ill effect 
was muscular soreness for 24 hours. 
S. J. Meyers (Miss. Valley Med, 
Jour., Nov., 1917). 

Effusions.—To prevent the recur¬ 
rence of serous effusions in the pleura, 
the peritoneum, the tunica vaginalis, 
etc., after aspiration, by reducing the- 
permeability of the local capillaries and 
restoring the circulatory equilibrium. 
From 8 minims to 2 drams (according 
to the size of the cavity) of supraren- 
alin or adrenalin, in four times the 
quantity of saline solution, should be 
injected into the cavity. 

Disorders of Pregnancy and Par¬ 
turition.—The most useful employ¬ 
ment of adrenal preparations in dis¬ 
orders of this class is in obstinate 
vomiting of pregnancy. This was 
suggested by the frequency and ob¬ 
stinacy of vomiting in Addison’s dis¬ 
ease and the beneficial influence of 
adrenal gland over this symptom. The 
benefit is probably due to the more 
active destruction of toxic wastes— 
which are increased during preg¬ 
nancy owing to the presence of the 
fetus—a function in which we have 
seen the adrenals take part. 

Severe case of hyperemesis gravi¬ 
darum of more than two months’ 
duration treated with marked success 
by means of adrenalin in small doses. 
Various remedies had been tried, and 
artificially induced labor was seriously 
contemplated. S. Rebaudi (Gazz. 
degli Osped.; Zentralbl. f. Gynak., 
Nu. 44, 1909). 

Cancer.—The fact that the cancer¬ 
ous growths in mice and rats had 
been caused to disappear by the injec¬ 
tion of the active principle into these 
growths suggested that the latter might 
also prove efficacious in man. About 
all that can be said for the present is 
that the results warrant further trial. 


ANIMAL EXTRACTS (SAJOUS). 


759 


Second series of experiments in the 
Konig Charite on private patients on a 
larger scale, based on Reicher’s 
experiments in animals. The writer 
gave to men an average of 0.2 to 0.3 
Gm. to begin with and increased up to 
1 Gm. of the original solutions of ad¬ 
renalin, selecting cases which did not 
suffer from bad heart disease or cal¬ 
cification of arteries. The best results 
were obtained in a boy of 12 years who 
suffered from sarcoma of the vertex. 
Within three and a half weeks the 
tumor was reduced to one-third of its 
size. The remaining third was made to 
disappear under the Christian Muller 
method of X-rays and high frequency 
combined. Since six months the tumor 
has undergone complete retrogression ; 
no recurrence has occurred. The 
writer also reduced temporarily sev¬ 
eral cases of malignant lymphoma. 

He has since tried to treat other in¬ 
operable tumors, among others a mel- 
anosarcoma, which was identified as 
such under the microscope. It was a 
metascasis in the groin which occurred 
one and a half years after excision of 
the primary tumor on the dorsum of 
the foot. Within one and a half 
months it had increased to the size of 
of a man’s fist. In three months he 
was able to reduce its size very little, 
but, at least, it has become stationary, 
while before it was growing very 
rapidly. It is remarkable that during 
the treatments the patients increased 
much in weight—up to 14 pounds in his 
series. There must be a constant 
anomaly of metabolism somewhere. 
Reicher (Berl. klin. Woch., Nu. 20, 
1911). 

The desensitizing of the skin by 
means of adrenalin permits the use of 
nearly double the dose of the X-rays 
for a period of from fourteen to 
eighteen days. The most important 
indication for this method is the 
treatment of malignant tumors sit¬ 
uated subcutaneously. Reicher and 
Lenz (Miinch. med. Woch., June 13, 
1911). 

Case of squamous-celled carcinoma 
of the cheek treated with X-rays and 
later with radium, with very little, if 


any, improvement. To assist the 
penetration of the rays, applications 
and injections of adrenalin (1:1000) 
were employed. The injections were 
discontinued, being followed by local 
edema, but the applications were 
continued for some time. Great im¬ 
provement resulting, a daily dress¬ 
ing of lint soaked in adrenalin solu¬ 
tion was applied, the radium treat¬ 
ment being discontinued. The ulcer 
healed gradually and 6 years later 
there had been no recurrence. L. C. 
Peel Ritchie (Lancet, June 29, 1912). 

The writer saw benefit follow a 
single injection of adrenalin in can¬ 
cer, evidently made as a test. Rosen¬ 
berg was obliged to discontinue ad¬ 
renalin injections because of the pain 
caused. Graffner (Berl. klin. Woch., 
Nov. 20, 1912). 

Case of carcinoma of the tongue, 
the size of a hen’s egg, which had 
necessitated tracheotomy, in which 
the writer tried injecting a few drops 
of adrenalin, gradually increasing to 
2 Gm. (30 grains) a day. The tumor 
began to undergo gangrene and to be 
thrown off, the remaining mass being 
snared off. Holscher (Annales des 
Mai. de I’Oreille, du Lar., du Nez et 
du Phar., 7 Liv., 1912). 

Case of inoperable carcinoma of 
the pharynx with cachexia and swell¬ 
ing of the cervical glands treated 
with a tabloid containing fresh thy¬ 
roid 6 grains (0.4 Gm.), adrenal 
grain (0.048 Gm.), pituitary Yig grain 
(0.004 Gm.) one night and morning,. 
The improvement was slow but 
steady. In 4 months, an additional 
capsule being given daily, she could 
swallow all foods if well masticated, 
except meat. In 5 months she re¬ 
sumed work, improving steadily, hav¬ 
ing considerably increased in weight. 
J. T. Shirlaw (Liverpool Med.-Chir. 
Jour., July, 1913). 

Osteomalacia.—In osteomalacia the 
adrenal preparations find a normal in¬ 
dication in view of their stimulating in¬ 
fluence on metabolism and, therefore, 
general nutrition, in which the osseous 
system must normally partake. This 


760 


ANIMAL EXTRACTS (SAJOUS). 


beneficial process is further enhanced 
by the fact that the thyroid apparatus 
is itself stimulated through the same 
cause, and that the thyroid secretion, 
as shown by Macallum, Parhon, and 
others, actively promotes calcium me¬ 
tabolism. 

The writer collected 47 cases 
treated with adrenalin, 11 pregnant 
and 35 non-pregnant women. Of the 
former 45 per cent, were cured and 
about 18 per cent, improved; of the 
latter 17 per cent, were cured and 40 
per cent, improved. R. Cristofoletti 
(Gynak. Rundschau, v, 113; 169, 1911). 

LOCAL USE.—To check hemor¬ 
rhage from wounds, adrenalin can be 
used in various organs. 

In free hemorrhages from mucosae 
or in simple congestion of the latter, 
local application of the extract is 
quite sufficient for hemostasis. In a 
parenchymatous hemorrhage, in the 
course of an operation, the indication 
is filled in the same manner. Satre 
(Le Prog. Med., July 8, 1917). 

Bates, Dor, and many other oph¬ 
thalmologists have introduced the lo¬ 
cal application of a weak solution 
to the conjunctiva to produce a blood¬ 
less field, and also to enhance the 
local effects of cocaine, atropine, es- 
erine, and other agents used in the 
eye. Weak solutions may also be used 
in conjunctivitis. 

Instillations of 4 to 5 drops of the 
1: 1000 solution of adrenalin or sub¬ 
conjunctival injections of a smaller 
quantity causes a primary reduction, 
followed by a marked increase in ten¬ 
sion, Subsequently there is a secondary 
reduction of tension. These changes 
are observed in normal as well as 
glaucomatous eyes. The reaction in 
normal eyes is not very great, but in 
glaucomatous eyes it is quite marked. 
In normal eyes, the effect of the adren¬ 
alin passes away in a few hours, 
whereas in glaucomatous eyes the effect 
continues for several days. 


In a certain number of cases of 
glaucoma the adrenalin produced a 
lowering of tension, whereas in others 
it caused attacks of acute exacerbation. 
Repeated instillations in normal eyes 
are apparently without much effect, but 
in glaucomatous eyes there is a marked 
increase in tension after the final in¬ 
stillation, The result of the combined 
use of eserine and adrenalin on tension 
indicate the two opposing forces are at 
work. Therefore, in eyes that have a 
predisposition to glaucoma it is advis¬ 
able to combine eserine with the adren¬ 
alin. J. Rubert (Zeit. f. Augenheilk., 
Bd. xxi, S. 97, 224, 1909). 

. In 50 cases of conjunctival hyper¬ 
emia from causes varying in nature 
from simple congestion due to eye- 
strain to the most severe types of 
conjunctivitis, a single drop of ad¬ 
renalin chloride solution, 1:5000, in 
the conjunctival sac almost imme¬ 
diately caused a blanching of the 
membrane, commencing in about ten 
seconds, and reaching a maximum 
in from five to ten minutes, the effect 
lasting from one-half to two hours, 
according to the nature of the case. 
The blanching effect may be obtained 
by even a solution of from 1: 12,000 
to 1: 10,000 in from thirty seconds to 
two minutes. A solution of 1:2000 
was found to give the best results in 
operative work upon the eye, causing 
no irritation that could be noted upon 
close observation. A 2 per cent, solu¬ 
tion of cocaine hydrochloride was used 
ten minutes prior to the instillation of 
the adrenalin, when operation was con¬ 
templated, in order that the effect of the 
anesthetic might not be interfered with, 
thus insuring a painless and almost 
bloodless result. MacFarlane (Can. 
Practitioner, June, 1909). 

This applies as well to the local use 
of adrenal extractives in the nose, 
pharynx, and larynx, a weak solution 
of cocaine, 4 per cent., for example, 
acquiring the power of 15 to 20 per 
cent, solution, both as anesthetic and 
styptic. Combined with B-eucaine 
(5 c.c. of 1 per cent, solution), supra- 


ANIMAL EXTRACTS (SAJOUS). 


761 


renalin, or adrenalin, 3 drops of the 
1: 1000 suffice when injected in small 
quantities into the tissues, or, applied 
locally to mucous membranes, are 
quite effective for operations in al¬ 
most any region, including the 
urethra. The cocaine and adrenalin 
solution referred to above is equally 
effective, the operation being performed 
after three or four minutes. These so¬ 
lutions are extensively used, especially 
for dental, uterine, rectal, and urethral 
operations. 

Hemorrhoids.—Bouchard intro¬ 
duced the use of tampons soaked in 
adrenal preparations for the treatment 
of this condition. In external piles, es¬ 
pecially if there is great distention and 
hemorrhage, 20 drops of suprarenalin in 
2 drams of saline solution applied with 
a compress relieve greatly the conges¬ 
tion and the pain. A small quantity of 
cocaine enhances these beneficial ef¬ 
fects. 

The writer obtained a rapid retrac¬ 
tion of hemorrhoidal tumors by giv¬ 
ing a single injection of 0.5 c.c. (8 
minims). This dose will reduce a 
hemorrhoid the size of a walnut 
within a week’s time. A hemorrhoid 
the size of an apple was greatly re¬ 
duced by 15 injections given during 
7 weeks. The drug is injected under 
the mucosa, as is done for anesthesia 
of the mucous membrane. H. Kruk- 
enberg (Miinch. med. Woch., July 
30, 1918). 

Neuralgia, Sciatica, and Neuritis. 
—To subdue and sometimes arrest pain 
in these disorders, by causing ischemia 
of the hyperemic and, therefore, over¬ 
sensitive nerves. One to 2 minims of 
a 1:1000 suprarenalin or adrenalin 
ointment applied by inunction over the 
painful area. 

Cutaneous Disorders.—Local appli¬ 
cations of the 1:1000 solutions of su- 
pracapsulin, adrenalin, etc., may be 


used advantageously to assuage pain 
and counteract inflammation, which 
they do by causing constriction of 
the arterioles. Among the conditions 
in which they have proven useful are 
toxic erythema, urticaria, acne, sun¬ 
burn, bee-sting, eczema, chilblains, ar¬ 
thralgia, arthritis, varicose veins, 
bums. X-ray dermatitis, and herpes 
zoster. 

The vasoconstrictor property of 
epinephrin was taken advantage of 
by the author in 3 cases of erythema 
of the face (“red nose”), 2 of the pa¬ 
tients being young men, and the third 
a young lady. A solution of epi¬ 
nephrin hydrochloride, 1:1000, was 
given internally in 5-minim doses in 
water 3 times daily Yi hour before 
food, and the treatment continued 
during 5 to 6 months with short in¬ 
tervals. The erythema almost en¬ 
tirely disappeared, and lj4 years after 
treatment it had not reappeared. No 
bad effect on the heart or blood- 
pressure was observed. Rothmann 
(Lancet; Charlotte Med. Jour., Oct., 
1913). 

PITUITARY ORGANOTHER¬ 
APY. 

“We may assume,’’ wrote Schafer 
in 1898, in a review of the investiga¬ 
tions on the physiological role of this 
organ, “that the pituitary body fur¬ 
nishes to the blood an internal secre¬ 
tion, and that this internal secretion 
tends to increase the contraction of the 
heart and arteries, and perhaps influ¬ 
ences nutrition of some of the tissues, 
especially bone and the tissues of the 
nervous system.” Howell showed, how¬ 
ever, that of the two lobes of the organ 
extract of the anterior lobe produced 
no effect—a fact confirmed by several 
investigators—and that the main action 
of extracts of the posterior lobe was 
to slow the heart and raise the blood- 
pressure. Schafer and Vincent then 


762 


ANIMAL EXTRACTS (SAJOUS). 


concluded, after experiments, that the 
pituitary contained both a pressor and 
a depressor substance. The latter 
effect is increasingly being disregarded 
in practice, the posterior lobe, now offi¬ 
cial (U. S. P., 1916), giving rise to 
pressure effects. 

Doses of 15 to 20 minims of pituitrin 
produce a perceptible increase in the 
blood-pressure in from four to twenty 
minutes, and maintain it from twenty 
minutes to an hour or even longer, 
differing in this respect from adrenalin, 
in which the effect is far more tran¬ 
sient. There is a coincident change in 
the pulse rate, diminishing as the blood- 
pressure increases and increasing as it 
falls. However, this change is more 
gradual, both in its downward course 
and its return to normal. 

The rise in blood-pressure varies 
from 8 to 38 mm., while the pulse rate 
falls from 4 to 17 beats per minute. 
No untoward effects were noted in any 
of the cases in which larger or repeated 
doses were administered. The inhibi¬ 
tory influence upon the pulse is more 
lasting than the influence upon the 
blood-pressure. H. G. Beck and J. J. 
O’Malley (Amer. Med., Oct, 1909). 

In animals intravenous injections 
of pituitrin in small dosage can be 
repeated at intervals of 10 or 15 min¬ 
utes without significant failure of 
their pressor effect in animals. In 
either the dog or cat occlusion of 
the adrenal circulation does not 
diminish the pressor effect of a 
standard dose of pituitrin. There is 
probably, therefore, no direct de¬ 
pendence on adrenal functioning upon 
.pituitary secretion. Hoskins and 
McPeek (Amer. Jour. Physiol., Sept. 
2, 1913). 

The effect of pituitary extract on 
the human blood was by no means 
found uniform by the writer, and did 
not correspond to the striking re¬ 
sults obtained in animal experimenta¬ 
tion. As previously shown by von 
der Velden, pituitary extract caused 
no constant rise in blood-pressure 
and no change in the pulse-rate or in 


the respiration-rate. Nor was there 
any special effect on the general sys¬ 
tem. Behrenroth (Deut. Archiv f. 
klin. Med., cxiii, Nu. 3-4, 1914). 

The pressor substance was looked 
upon as resembling that of adrenal ex¬ 
tracts, its application to mucous mem¬ 
branes producing blanching, as is the 
case with adrenalin. With Herring, 
Schafer then found that pituitary ex¬ 
tract was endowed with powerful di¬ 
uretic properties, and that it produced 
dilatation of the organ. Finally, Her¬ 
ring advanced the theory that the se¬ 
cretion was formed in the anterior lobe 
and completed in the posterior lobe, 
and that it then passed into the third 
ventricle, to mix therein with the cere¬ 
brospinal fluid. 

From my viewpoint, the prevailing 
idea that either lobe of the pituitary 
is a secreting organ was based on an 
assumption at the start, and has been 
perpetuated as such. The effects of its 
extracts are those of the adrenal prin¬ 
ciple which the posterior pituitary con¬ 
tains; not only does the pressor sub¬ 
stance give the actions of chromaffin 
substance, due to the presence of the 
adrenal principle, but it produces the 
same effects. The functions I have at¬ 
tributed to the pituitary are totally dif¬ 
ferent; but as they.do not bear in any 
way upon the valuable therapeutic ef¬ 
fects of this organ, they need not be 
described in the present connection. As 
I view it, therefore, pituitary prepara¬ 
tions merely afford an additional and 
efficacious way of administering adre¬ 
nal preparations. Being bound up in 
organic combination, the adrenal prin¬ 
ciple acts with less violence, owing, 
probably, to the fact that even in the 
tissues, after the pituitary preparation 
has been injected, the product is de¬ 
composed very slowly. 


ANIMAL EXTRACTS (SAJOUS). 


763 


The writer found that extract of 
suprarenal and pituitary glands had a 
rapid and marked effect as pupil dila¬ 
tors. Thyroid had no mydriatic 
effect. Catapano (Deut. med. Woch,, 
Jan. 31, 1911). 

Comprehensive experiments in dogs 
led the writers to conclude that 
pituitrin injected intravenously caused 
a moderate rise of the blood-pres¬ 
sure, slowing of the pulse rate, and a 
temporary arrest of the urinary ex¬ 
cretion, without true secondary poly¬ 
uria. The rise in blood-pressure is 
more marked when the normal tonic 
activity of the vagi has been sus¬ 
pended or the terminations of this 
ner e paralyzed. It is due to a vis¬ 
ceral and peripheral vasoconstriction, 
which appears to occur independently 
of th? general vasomotor center. The 
diminution of uri lary excretion pro¬ 
duced by pituitrin is dependent upon 
a renal vasoconstriction which seems 
to be of peripheral origin. In the 
whole animal the action of adrenalin 
is exerted in the same direction as 
that of pituitrin, but is more power¬ 
ful and also more evanescent. It dif¬ 
fers from pituitrin in increasing the 
amplitude of, and accelerating the 
contractions of, the isolated heart. 
Beco and Plumier (Bull, de TAcad. 
de Med. de Belg., xxvii. No. 5, 1913). 

Pituitary extracts, when prepared 
by certain methods, yield color re¬ 
actions suggesting epinephrin or an 
epinephrin-like compound. The phys¬ 
iologic actions of such solutions can 
be explained by the presence of such 
a compound, modified by admixed 
substances. That epinephrin has not 
yet been isolated from these glands 
may be due to the small amounts 
present. Watanabe and Crawford 
(Jour, of Pharmacol, and Exper. 
Therap., Jan., 1916). 

Whichever opinion ultimately pre¬ 
vails, the fact remains that pituitary is a 
valuable remedial agent in many disor¬ 
ders. Its marked advantage is that it 
sustains the rise of blood-pressure, to 
which it gives rise much longer than 


does adrenalin, thus being more re¬ 
liable in shock and other emergency 
cases. It seems also to sustain the tem¬ 
perature and the muscular tone, car¬ 
diac, vascular, intestinal, and uterine, 
longer than the adrenal active principle. 
It possesses also a great practical ad¬ 
vantage over adrenalin and other adre¬ 
nal principles in that it can be admin¬ 
istered by the mouth without compro¬ 
mising its effects. 

At the present writing (1921) pitui¬ 
tary preparations (posterior lobe) are 
looked upon as capable of raising the 
blood-pressure, of enhancing the con¬ 
tractile power of the uterus, and by 
dilating the renal vessels of producing 
diuresis. 

PREPARATIONS AND DOSE. 

—Pituitary gland is available in drug 
stores in the form of powder or tablets 
of desiccated gland. The new U. S. P. 
(1916) has made official a powder {hy¬ 
pophysis sicca) of the posterior lobe, 
the active one therapeutically, the dose 
of which is 34 grain (0.03 Gm.). The 
prevailing tendency is to give too large 
a dose of pituitary. I have seen very 
harmful effects produced by such medi¬ 
cation. I seldom prescribe over 34o 
grain (0.006 Gm.) three times daily. 

A product called “pituitrin” by its 
manufacturers, in the form of a solu¬ 
tion, is available on our market for oral 
or intramuscular use, the dose of which 
is given as 10 to 30 minims (0.66 to 
2 C.C.). 

There is also a liquid extract of the 
posterior lobe, wrongly termed “infun¬ 
dibular extract,” the infundibulum be¬ 
ing the pedicle which unites both lobes 
of the pituitary to the base of the 
brain. This infundibular extract affects 
mucous membranes precisely as do 
adrenal extractives, and should be ap¬ 
plied only when diluted in eight or ten 


764 


ANIMAL EXTRACTS (SAJOUS). 


times the same quantity of saline solu¬ 
tion. It may be given orally in 10- to 
30- minim (0.62 to 2 c.c.) doses, or 
intramuscularly in 3- to 15- minim 
(0.2 to 0.92 c.c.) doses. 

Liquor hypophysis, U. S. P. (solu¬ 
tion of hypophysis), is a preparation 
containing the water-soluble principles 
from the fresh posterior lobe of cattle. 
It is standardized for uterine activity 
on the isolated uterus of the virgin 
guinea-pig, and is officially required to 
be kept in a sterile condition in glass 
containers. Dose, 5 to 15 minims (0.3 
to 1 C.C.). 

An, important addition to our pituitary 
pharmacological agents was made re¬ 
cently by Prof. T. B. Robertson of the 
University of California and now of the 
University of Toronto. He terms tethelin 
a substance isolated in relatively pure form 
from the anterior lobe of ox pituitary. It 
was found to retard the early growth of 
animals, but to markedly accelerate post¬ 
adolescent growth. The animals receiving 
it were smaller but heavier than controls, 
and showed favorable effects on their 
skins. Animals deprived of food for a 
time and then given unlimited food, re¬ 
gained weight more rapidly when given 
tethelin than controls. It stimulated the 
healing of wounds. The substance has 
marked powers in influencing the growths 
of tissue. It was given orally and hypo¬ 
dermically with the same results. 

THERAPEUTICS.—Acromegaly. 

—The possible value of pituitary ex¬ 
tracts here suggested itself, but, al¬ 
though a few of the symptoms, the 
headache, lethargy, and amnesia, were 
relieved in some, no cures were ob¬ 
tained. Analysis of the cases reported 
benefited suggests an explanation apart 
from the organ as the source of an in¬ 
ternal secretion, but entirely in keeping 
with the presence in the pituitary prep¬ 
aration of adrenal secretion in organic 
combination. Marinesco observed that 
it was the extremely violent headaches 


that were relieved, there being no benefit 
otherwise, excepting perhaps increased 
diuresis. Kuh, obtaining no favorable 
result, withdrew the remedy, but the 
patient begged to be given the powders 
again, having found his headache much 
more intense when he failed to take 
them. The same observation had been 
recorded by Cyon, the patient, an obese 
child of 12 years, having besides lost 
twenty pounds in weight. What benefit 
was obtained in 1 case out of 7 cases 
treated by Kinnicutt was also limited 
to the headache and neuralgia. Les- 
zynsky, after a prolonged trial in 2 
cases, wrote: “While some published 
reports as to the efficacy of the prep¬ 
arations of the sheep’s gland have 
seemed quite encouraging in so far as 
the relief of headache and of paresthesia 
of the hands is concerned, it is the 
general consensus of opinion that it in 
no way influences the progress of this 
disease.” 

Still, the relief of the headache and 
paresthesise indicates some potent ac¬ 
tion. This is accounted for if the adre¬ 
nal principle is considered as the active 
agent of the pituitary preparations, 
since, as Langley has shown, it is prin¬ 
cipally upon the arterioles that the 
adrenal principle acts, a view which 
has now become classic. Such being 
the case, the tumor of the pituitary, or 
the compressed tissues around it, re¬ 
ceive less blood through their con¬ 
stricted arterioles, and the sensory ter¬ 
minals of the peripheral likewise. The 
resulting ischemia of these tissues thus 
accounts for diminution of pain—as 
long only as the remedy is administered. 

Cardiac Disorders.—As shown by 
Renon and Delille, pituitary gland 
raises the depressed arterial tension and 
corrects purely functional disorders of 
rhythm. 


ANIMAL EXTRACTS (SAJOUS). 


765 


It is recommended in doses ranging 
from 3 to 6 grains (0.2 to 0.4 Gm.) of 
the whole gland in myocardial weak¬ 
ness, particularly in that due to infec¬ 
tions when the blood-pressure is reced¬ 
ing, the pulse is becoming more rapid, 
and the urine scanty. While less active 
than digitalis as a diuretic, it, neverthe¬ 
less, serves a valuable purpose in this 
connection. It is advantageous in mi¬ 
tral disorders when there is hyposys- 
tole and in chronic myocarditis, par¬ 
ticularly that due to alcoholism. It 
is also useful in the tachycardia of 
certain neuroses and during meno¬ 
pause. These results have been con¬ 
firmed by Trerotoli, Parisot, and 
others. 

It is contraindicated in aortic affec¬ 
tions in any disorder in which high vas¬ 
cular tension prevails, and where there 
is a tendency to anginal pains, which it 
tends greatly to aggravate. 

Pituitary gland is preferred to adre¬ 
nal preparations and particularly adren¬ 
alin when the action is to be sustained, 
the former being useful in urgent cases. 
Renon and Delille, however, prefer 
digitalis, and recommend pituitary 
gland only when the latter fails. Leon¬ 
ard Williams, on the other hand, deems 
it superior to digitalis, strophanthus, 
strychnine, and other classic tonics in 
what he terms the “runaway heart of 
toxic states,*’ influenza, pneumonia, 
bronchitis, etc., with tachycardia, but 
low blood-pressure, and in all cases in 
which there is posttoxic cardiac debil¬ 
ity. In these cases—which, from my 
viewpoint, are instances of pure hypoa- 
drenia—Williams regards pituitary 
preparations superior to any remedy 
at our command. 

In heart-failure and shock, it has 
been highly recommended, 15 minims 
(0.92 c.c.) of the extract being injected 


intramuscularly. While its virtues 
would seem to recommend it for the 
perpetuation of the effects of adrena¬ 
lin, which are, at best, but temporary, 
the number of cases in which it has 
been tried has been too limited so far 
to warrant an opinion as to its actual 
value. 

In 3 cases of heart-failure during 
anesthesia the writer injected 1 c.c. 
of a 20 per cent, solution of the poste¬ 
rior lobe of the pituitary body intra¬ 
muscularly. The effect was almost 
immediate, and the almost impercep¬ 
tible pulse soon became large and bound¬ 
ing. This effect lasted from twelve to 
sixteen hours, and gradually passed off. 
Not only did the pulse become larger 
in expansion, but it was also slowed, 
and, whereas it had been irregular, it 
became regular. This effect seems due 
not only to the action of the drug on 
the blood-vessels, but also on the heart. 
The injection was given in conjunction 
with normal saline by rectum. G. G. 
Wray (Brit. Med. Jour., Dec. 18, 1909). 

The benefit which follows the use of 
pituitrin by intramuscular injection 
when the blood-pressure is abnormally 
low is very marked. The writer recom¬ 
mends it especially for threatened 
collapse and hemorrhage after child¬ 
birth. He thinks it may prove of 
value in surgical shock and in acute 
febrile states, but his use of it in 
these cases has not yet been exten¬ 
sive. Pituitrin has two advantages 
over adrenalin: namely, its action is 
moderate and prolonged. Klotz 
(Miinch. med. Woch., May 23, 1911). 

While the treatment of low blood- 
pressure in infectious diseases by in¬ 
jections of adrenalin is very success¬ 
ful, it is not perfectly satisfactory, 
Staub having shown that only 6 per 
cent, of the drug reaches the circulat¬ 
ing blood, while the remainder is 
disintegrated at the site of injection, 
while large doses may cause suppura¬ 
tion, and even extensive necrosis of 
the skin at the site of injection and 
also glycosuria. The author has, 
therefore, substituted pituitrin on ac- 


766 


ANIMAL EXTRACTS (SAJOUS). 


count of its powerful action on un- 
striated muscle. H. von Willebrand 
(Finska laekere Handl., vol. liv, 
1912). 

The writer recommends pituitrin in 
acute heart failure with dilatation. 
Too large a dose may in the aged 
result, however, in a sudden harmful 
rise of pressure. This may entail 
hemorrhage and apoplexy. A weak¬ 
ened and tired-out myocardium may 
be rapidly reduced to a normal size. 
E. Zueblin (Boston Med. and Surg. 
Jour., Dec. 24, 1914)). 

After using posterior pituitary 
(pituitrin) in over 1000 cases with 
cardiovascular and metabolic atony 
and deficient defensive activity the 
writer regards pituitary therapeutics as 
easily the most effective resources at 
our command in organotherapy. R. 
A. Bate (Louisville Mthly. Jour, of 
Med. and Surg., Sept., 1915). 

Obstetrics.—Dale found, in the 
course of comprehensive experiments, 
that (in keeping with that of the adre¬ 
nal principle) the action of extract of 
pituitary was “a direct stimulation of 
involuntary muscle without any rela¬ 
tion to innervation.” Frohlich and 
Frankl-Hochwart then ascertained that 
it caused contractions of the pregnant 
uterus in rabbits, while Foges and Hof- 
statter resorted to this property in so 
far as the human uterus was concerned 
to check post-partum and other uterine 
hemorrhages, the test including 63 
cases. The extract proved worthless 
by the mouth; but when injected intra¬ 
muscularly, marked uterine contraction 
appeared within five minutes and lasted 
a long while in most cases. It is espe¬ 
cially efficient in placenta praevia, 
particularly after version'and expul¬ 
sion of the fetus, removal of the 
placenta is accompanied by profuse 
hemorrhage. It is also useful in 
cases of normal labor followed by 
hemorrhage or uterine relaxation. 


In 63 cases of post-partum hemor¬ 
rhage and after 1 abortion the intra¬ 
muscular injection of pituitrin (in 
doses of 1 to 2 c.c.) proved superior to 
ergotin with reference to the intensity 
of the contraction and continuance of 
the excitability. The authors were en¬ 
abled to note the effect of pituitrin 
particularly in 6 cases of extraperi- 
toneal Cesarean section. “After not 
more than five minutes one could see 
how the exposed uterus contracted, in 
response to a light tactile irritation, to 
a firm ball. The action continued for 
a long time, which accounts for the fact 
that there was no hemorrhage, a com¬ 
plication that is always feared in con¬ 
nection with Cesarean section.” In 
accordance with their observations, the 
authors are of the opinion that there is 
no doubt concerning the specific effect 
of pituitrin upon the excitation of the 
uterus. Foges and Hofstatter (Zen- 
tralbl. f. Gynak., Nu. 46, 1910). 

Pituitary liquid in placenta previa, 
in c.c. (8 minims) dosage, with 
advisable repetitions during the latter 
part of the first stage, and a single 
large dose (1 to 1^ c.c.—16 to 24 
minims) when dilatation is complete, 
is recommended by the writers, their 
results having been uniformly good. 
Gallagher and Gallagher (Surg., 
Gynec. and Obstet.; Amer. Med., 
Dec., 1916). 

Small doses of pituitary extract 
without any curettement or packing 
are recommended by the writer in 
incomplete abortion and placenta 
previa. He usually gives c.c. (8 
minims) pituitary liquid hypoder¬ 
mically daily or every other day until 
the placenta is expelled. This oc¬ 
curred in most cases in 2 or 3 days 
and in but 1 in 5 days. The bleeding 
during the time does not exceed that 
of an ordinary menstrual period. 
Lipkins (N. W. Med., Mar., 1918). 

The trend of recent clinical observa¬ 
tions is that if pituitrin is used at all 
in obstetrics, it should be in smaller 
doses even in cases of uterine inertia, 
full doses exposing the uterus to rup- 


ANIMAL EXTRACTS (SAJOUS). 


767 


ture and the fetus to asphyxia. It is 
especially dangerous in primiparse. 

A case was observed in which after 
evacuation of the uterus after abor¬ 
tion, pituitary and ergotin were given 
for hemostasis. The pulse became 
very poor and soon afterwards the 
woman collapsed. Hemorrhage had 
wholly ceased. Intravenous saline in¬ 
fusion alone produced a reaction, but 
only after some hours. The condi¬ 
tion is best explained by synergism of 
2 drugs which alike cause excessive 
contraction of the blood-vessels 
facilitated by the great loss of blood. 
Bovermann (Miinch. med. Woch., 
July 9, 16, 1912). 

The following complications have 
followed the use of pituitary extract 
in labor cases: Post partum uterine 
atony, fetal asphyxia, maternal col¬ 
lapse. eclamptic convulsions, tetanus 
of the uterus, premature placental 
separation and rupture of the uterus. 
In his own experience uterine tetanus 
followed as little as 5 minims (0.3 
c.c.) of the extract in 2 instances. A 
greater tendency to tetanus in primi- 
parae than in multiparae was noticed, 
and in many instances restoration of 
normal contractions did not follow, a 
low forceps operation becoming 
necessary. Fetal asphyxia was like¬ 
wise noted in many primiparae, though 
never fatal. Post partum atony, with 
alarming hemorrhage in several cases, 
was noted particularly in prolonged 
labor and in multiparae in whom sev¬ 
eral pregnancies had occurred in 
rapid succession. The drug has no 
place in normal obstetrics. L. G. 
McNeile (Amer. Jour, of Obstet, 
Sept., 1916). 

Within 12 weeks of each other 
there had been admitted to the ob¬ 
stetric ward of the Delaware Hos¬ 
pital 2 patients with spontaneous rup¬ 
ture of the uterus, following the ad¬ 
ministration of a single dose of 1 c.c. 
(16 minims) of pituitary solution. 
They had met the usual indications 
for the use of pituitary solution. 
Both pelves were practically normal 
and the conjugata vera, as estimated 


at operation, at least 10 cm. in each. 
But both babies were found to be 
somewhat above the average size, one 
weighing a little above and the 
other a little below 4500 Gm.—9.9 
pounds. One patient died, the other 
recovered. W. Wertenbaker (Jour. 
Amer. Med. Assoc., Ixviii, 1895, 1917). 

After testing pituitrin in a large 
number of labors, the writers advo¬ 
cate very small doses by the intra¬ 
muscular injections, their average 
dose being 2 to 4 minims (0.12 to 
0.25 C.C.), and in labor at term ex¬ 
clusively—never for the induction of 
abortion or premature labor, where it 
fails entirely. It is only indicated 
after the onset of labor for strength¬ 
ening the uterine contractions; also 
in combination with castor oil for 
the induction of labor at full term. 
These small, entirely harmless doses 
of pituitrin serve to reduce the need 
for the application of forceps, thus 
causing otherwise instrumental de¬ 
liveries to terminate like normal pro¬ 
gressive labors. Stein and Dover 
(Med. Rec., Aug. 11, 1917). 

Analyses of the reports of 5245 
cases of labor in which pituitrin was 
used strikingly emphasized the fact 
that the contents of 1 ampoule (15 
minims—1 c.c.) is much too large a 
dose and that this should be reduced 
to ^ of that dose, which may be re¬ 
peated at intervals of 30 to 50 min¬ 
utes if necessary. The first dose is 
usually decidedly more effective than 
the subsequent ones. The field of 
usefulness for this drug is sharply 
limited. This is secondary inertia 
late in the second stage in multip¬ 
arous women who have had previous 
unobstructed labors, a normal presen¬ 
tation, fully dilated cervix, head 
moulded and through the brim, mem¬ 
branes ruptured, and perineum re¬ 
laxed. In such cases its use fre¬ 
quently avoids a low forceps opera¬ 
tion. An anesthetic should be given 
when the action of the pituitary ex¬ 
tract begins, and one should always 
be prepared to complete delivery with 
forceps. It is inferior to ergot for 
the control of postpartum hemor- 


ANIMAL EXTRACTS (SAJOUS). 


rhage. It should never be used in 
normal labor and it is dangerous in 
primiparae. Its use should invariably 
be preceded by accurate pelvimetry. 
In the cases analyzed there were 20 
of rupture of the uterus, 12 in the last 
year in a total of 1293 cases in which 
the drug was used. This gives 1 in 
each 106 cases. The danger to the 
fetus has increased during the past 
year, probably owing to the more 
reckless use of large doses. During 
1914 there were 27 fetal deaths in 
3952 cases, or 1 in 146 cases, while 
during 1916 there were 34 fetal deaths 
in 1293 cases, or 1 in every 38 cases. 
Dangerous fetal asphyxia is even 
more frequent. It is quite obvious 
that the field of safe usefulness of 
pituitary solution is very sharply 
limited and any transgression is 
fraught with considerable danger. J. 
J. Mundell (Jour. Amer. Med. Assoc., 
June 2, 1917). 

Indications for use of pituitrin are 
limited to simple uterine inertia in 
multiparae without fetal or maternal 
dystocia and in patients not exhausted. 
The author’s personal experience and 
observations of cases referred to the 
Lying-In Hospital, had led him to^ 
add his own to the warnings already 
published. Pituitrin in Cesarean sec¬ 
tion is not as certain as ergot. It is 
merely an aid to forceps in certain 
cases of dystocia where stimulation 
of the uterine contractions might 
drive the head to a more suitable 
level for instrumental delivery. Pitui¬ 
trin was of especial value in curettage 
for incomplete abortion, also useful 
in metrorrhagia of young girls and in 
older women with small fibroids or 
inflammatory lesions in the adnexal 
regions resulting in hyperemia. G. 
W. Kosmak (Trans. Amer. Med. 
Assoc.; N. Y. Med. Jour., June 29, 
1918). 

The writer has long opposed the 
use of pituitary in labor. Further 
experience has confirmed the opinion. 
Rupture of the uterus and laceration 
of the cervix has followed improper 
use of the drug. Asphyxia of the 
newborn has been caused and the en- 


docrinal relationships of the fetus 
have been disturbed. As to the use of 
the drug in cases of Cesarean section, 
it should not be given after the 
sutures were put in, as the sudden 
contraction may tear the sutures out, 
and peritonitis follow. In true pri¬ 
mary inertia with or without rupture 
of the waters pituitrin may do good. 
J. B. DeLee (Trans, Amer. Med. 
Assoc.; Med. Rec., June 22, 1918). 

In 3 cases of intestinal paresis fol¬ 
lowing operations for ovarian cyst 
and ectopic gestation, quite prompt 
relief was obtained by injections 
of pituitary extract. In a case of 
subinvolution of the uterus, the pa¬ 
tient suffering from menorrhagia, for 
which she had recently been curetted 
without result, and having soft, flabby 
tissues and low blood-pressure, Aarons 
decided to try the effect of repeated 
doses of pituitary extract. Six injec¬ 
tions were given in as many weeks. 
The uterus underwent contraction 
from 5 to 3 inches as measured by the 
sound; the general condition was much 
improved, and had remained so six 
months after the treatment. During 
the administration of the pituitary ex¬ 
tract marked polyuria was noted. No 
deleterious effects resulted. The author 
suggests, however, that the use of the 
extract in subinvolution be limited to 
cases with associated low blood-pres¬ 
sure. 

Ott and Scott found infundibulin, 
i.e., extract of the posterior lobe, to act 
as a powerful galactagogue in the 
goat. In practice its use has at least 
given rise to a temporary increase of 
secretory activity. 

The writers found that pituitrin not 
only increased the quantity of milk 
secreted, but also that it became rich 
in fats, although this increase is only 
temporary. The increase in quantity 
is not so marked, however, after sub- 


ANIMAL EXTRACTS (SAJOUS). 


769 


sequent doses. Hill and Simpson 
(Amer. Jour, of Physiol., Oct., 1914). 

Pituitrin was found to increase 
muscular activity, leading to con¬ 
striction of the milk ducts and alveoli 
of the active mammary gland, with a 
consequent expression of milk. This 
action prevailed also on the excised 
gland in the absence of any circula¬ 
tion. The flow of milk produced by 
pituitrin is dependent on the amount 
of milk present in the gland. There 
is no evidence of any true secretory 
action. The non-lactating gland, up 
to a late stage of pregnancy, is not 
sensitive to pituitrin. Gaines (Amer. 
Jour, of Physiol., Aug. 1, 1915). 

As a galactagogue the writer em¬ 
ploys pituitary extract by mouth with 
as great confidence as he does ergot 
to cause uterine contraction after 
labor. He has noted no unpleasant 
phenomena from it. Its action 
proved permanent. H. C. Hughes 
(Therap. Gaz., May, 1915). 


of febrile patients in 15 cases, 6 of 
whom had pulmonary tuberculosis, 3 
infectious sore throat, 1 exophthal¬ 
mic goiter, 3 lobar pneumonia, 1 sur¬ 
gical shock, and 1 convalescing from 
typhoid. From 1 to 1.5 c.c. (16 to 
24 minims) of extract of pituitary 
gland was injected deep into the 
muscle of the arm. The blood-pres¬ 
sures were taken several times be¬ 
fore the injection, and thereafter at 
intervals of about 15 minutes for 1 
hour or more. The pulse rate, tem¬ 
perature and rate of respiration were 
also noted. Aside from an occasional 
slowing of the pulse rate, which 
never exceeded 10 beats per minute, 
no definite change in these occurred. 
The rise in the diastolic pressure 
amounted in some instances to 15 
mm. Hg. or more, and this, together 
with its time and relative constancy, 
made it certain that it was due to the 
action of the drug. Schmidt (Arch. 
Internal Med., June, 1917). 


Infectious Diseases.—In this gen¬ 
eral class of disorders the use of pit¬ 
uitary acts, from my viewpoint, and 
in keeping with the effects of adre¬ 
nal preparations, by enhancing the im¬ 
munizing activity of the blood and the 
tone of the cardiovascular system. 
That such was the case in the infec¬ 
tious diseases in which it was tried can 
only, however, be surmised. 

Adrenalin and pituitrin were used 
in combination in cases of marked 
circulatory disturbances characterized 
by depression in children in pneu¬ 
monia, diphtheria, and typhoid. He 
injected 0.25 c.c. (4 minims) of a 
1:1000 pituitrin preparation and 0.5 
c.c. (8 minims) of a 1: 1000 adrenalin 
solution in young children, and 
double the dose in older children, 
repeated every 6 hours, about the 
duration of the rise of blood-pressure. 
In the interval camphor or caffeine 
was injected. P. Rohmer (Munch, 
med. Woch., June 16, 1914). 

The writer studied the effects of 
pituitary injections on blood-pressure 


Renon and Delille found that in 
typhoid fever it raised the blood- 
pressure, slowed the pulse, increased 
diuresis, and improved the patients in 
general, hastening convalescence no¬ 
ticeably. In diphtheria, in which the 
toxin reduces the vascular tension and 
promotes cardiac complications, it 
lowered the pulse rate, raised the 
blood-pressure, and increased diure¬ 
sis. In erysipelas it seemed to hasten 
the favorable evolution of the disease. 
In pneumonia it raised the blood- 
pressure when this became low, but 
without influencing favorably the evo¬ 
lution of the disease. In broncho¬ 
pneumonia, however, the opposite 
proved to be the case, considerable 
benefit being noted. Influenza was 
found to be very favorably influenced, 
rapid recovery resulting in patients 
aged, respectively, 80 and 63 years. 
This was confirmed by Azam, in the 
infectious form. Renon and Azam 
enumerate the phenomena which, in in- 


1-49 


7/0 


ANIMAL EXTRACTS (SAJOUS). 


fectious diseases, indicate the need of 
pituitary: 1, a fall of the arterial ten¬ 
sion; 2, quickening of the pulse and, 
as complementary minor phenomena, 
insomnia, anorexia, abnormal sweating, 
and heat flushes. Under the influence 
of pituitary there occur: 1, increase of 
arterial tension; 2, slowing of the pulse, 
with increase of power and amplitude; 
3, increased diuresis; 4, increase in 
weight; 5, hastening of convalescence. 

In several cases of tuberculosis 
treated by Renon and Delille, the re¬ 
sults were not, on the whole, encour¬ 
aging. In a case of Addison’s disease 
complicating tuberculosis, however, 
there was a notable rise of the blood- 
pressure and diminution of the asthe¬ 
nia. Trerotoli had already noted the 
beneficial effects of pituitary body in 
Addison’s disease—a fact which fur¬ 
ther suggests that the active agent of 
pituitary substance is its adrenal com¬ 
ponent. 

Exophthalmic Goiter.—Renon and 
Delille obtained considerable improve¬ 
ment in this disease by the use of pitui¬ 
tary gland. From the fourth to the 
fifth day, the sleeplessness, tremor, di¬ 
gestive disturbance, sweating, and sen¬ 
sation of heat were considerably les¬ 
sened. The tachycardia improved less 
rapidly, the pulse becoming slower 
gradually and attaining its slowest rate 
toward the fifteenth day. The arterial 
tension also rose steadily, attaining the 
maximum toward the third week, fall¬ 
ing again somewhat, but not to the for¬ 
mer low level. Some diminution of the 
exophthalmus occurred, but the goiter- 
was not reduced. The dose adminis¬ 
tered was 4% grains (0.30 Gm.) of 
the whole pituitary (ox) gland daily, 
a dose which they deem advisable to in¬ 
crease to 7% grains (0.50 Gm.) in di¬ 
vided doses daily. The symptoms tend 


to return, however, on discontinuing 
the remedy. Cases subsequently treated 
were also benefited, but no cures were 
effected. It is well to remember in this 
connection that the dose of the dried 
pituitary available in this country is but 

2 grains. 

This mode of action, from my view¬ 
point, corresponds precisely with that 
referred to under the preceding head¬ 
ing. We have seen that the main 
pathological condition—that to which 
all the prominent symptoms of exoph¬ 
thalmic goiter were due—was a gen¬ 
eral dilatation of the arterioles. Pit¬ 
uitary extract causing constriction of 
these vessels as long as it is admin¬ 
istered, it offsets for the time the 
morbid phenomena enumerated. That 
such is actually the case was demon¬ 
strated by Hallion and Carrion, who 
found, experimentally, that pituitary 
extracts “always produced their ef¬ 
fects by raising the arterial tension,” 
producing at the same time “an in¬ 
tense vasoconstrictor action upon the 
thyroid body.” Briefly, we have here 
precisely the physiological action nec¬ 
essary, the vasoconstrictor power of 
the adrenal component of the pitui¬ 
tary gland superseding the vasodila¬ 
tor action of the thyroid, the under¬ 
lying cause of the disease. 

Nervous and Mental Diseases and 
Myopathies.—Renon and Delille used 
pituitai*y in 10 neurasthenics in whom 
tachycardia; irregular vascular tension, 
often below normal; a sensation of op¬ 
pression, myasthenia, insomnia, and 
anorexia were present. In these cases 

3 to 5 grains (0.2 to 0.3 Gm.) daily 
proved remarkably useful, though no 
complete recovery was noted. This 
dose refers only of course to the whole 
gland. 

Delille and Vincent obtained a com- 


ANIMAL EXTRACTS (SAJOUS). 


771 


plete recovery in a grave case of 
bulbospinal myasthenia by the simul¬ 
taneous use of pituitary and ovarian 
extracts. Parhon and Urechia and 
Leopold-Levi and de Rothschild had 
also obtained favorable results with 
pituitary in similar cases. Browning 
observed good effects in cases of 
chorea in which this disorder occurred 
in conjunction with stunted growth, 
as shown under the next heading. 

In epilepsy it was tried by Mairet 
and Bose, but only served to increase 
the number ^of attacks—a result to be 
expected, since Spitska has shown that 
these were due to abnormal elevation 
of the blood-pressure. In some in¬ 
stances it provoked delirium. 

Sollier and Chartier tried pituitary in 
mental disorders and found it useful 
in depressive states. It raised the 
blood-pressure, reduced the pulse, sup¬ 
pressed profuse sweating, and improved 
the asthenia. The synthesis of percep¬ 
tions and the association of ideas were 
improved, and mental operations were 
incited more promptly. 

Stunted Growth and Imbecility.— 
In a case in which a child of 3 years 
had shown the evidences of hypothy- 
roidia with idiocy sufficiently to sug¬ 
gest the use of thyroid, Leopold-Levi 
and de Rothschild found this agent use¬ 
less. The case being attended with 
marked myasthenia, they adminis¬ 
tered pituitary extract, 1% grains 
(0.1 Gm.) twice daily, which corre¬ 
sponded with 7% grains (0.5 Gm.) of 
the fresh gland. Marked signs of im¬ 
provement appeared within a few 
days. The intelligence developed to 
a remarkable degree, and soon reached 
that of a child of a corresponding age, 
3 years, though before the treatment 
it did not exceed that of a 7 or 8 
months’ infant. Two similar cases, 


one of which showed symptoms of 
Little’s disease, were similarly bene¬ 
fited. 

Browning used pituitary only in 
undersized or backward children and 
youths (not real dwarfs or midgets), 
and obtained results both as height and 
weight in 4 cases described. The newly 
discovered tethelin is thought to have 
special properties in this direction. 

The daily addition of 50 to 75 Gm. 
(1% to ounces) of fresh desic¬ 
cated defatted anterior lobe of the 
ox to young dogs failed, except in 
some instances, to stimulate their 
growth as evidenced by their weight. 
Nor was their growth impeded. In 
white rats (Amer. Jour, of Physiol., 
Nov., 1912) the same investigator 
noted the inability of anterior lobe 
to stimulate growth. In fact, it 
seemed to impede growth. T. B. 
Aldrich (Research Lab. P., D. & Co., 
vol. i, 1913). 

The writers, in experiments in ani¬ 
mals, the gland being given in suffi¬ 
cient amounts to represent the relative 
weight of an average man, found that 
“neither anterior nor posterior lobes 
had any effect on the weight or 
growth of the animal.” Lewis and 
Miller (Arch, of Med., Aug. 15, 1913). 

The growth of young fowl was re¬ 
tarded by the addition to the diet of 
fresh, unmodified anterior lobe of ox 
pituitary, as shown both in body- 
weight and in length of the long 
bones. Involution of the thymus ac¬ 
companied this retardation and may 
have borne a causal relation to it. 
These effects are more marked in the 
males than in the females. R. Wul- 
zen (Amer. Jour, of Physiol., May, 
1914). 

A striking fact in the therapy of 
cretinism is that symptoms due to 
hypothyroidism clear up under pitui¬ 
tary gland. In a personal case there 
was a striking change in the contour 
of the hands, ankles, hips, buttocks, 
thighs and shoulders that could be 
made to appear or recede by giving 
or taking away pituitary gland. The 


772 


ANIMAL EXTRACTS (SAJOUS). 


effect on the child’s disposition was 
also striking. R. S. Haynes (Jour. 
Amer. Med. Assoc., June 19, 1915). 

The effect of giving 4 mg. (Yiq 
grain) of tethelin per day by mouth 
to mice for from 5 weeks onward, 
was found by the writer to be similar 
to that of pituitary tissue, viz., initial 
retardation of growth, followed by 
acceleration. Both effects were so 
exaggerated, however, as to involve 
total distortion of the curve of 
growth, the second growth-cycle 
being enormously prolonged, the 
third abbreviated and accelerated. T. 
B. Robertson (Endocrinology, Jan., 
1917). 

Intestinal Paresis.—Bell and Hicks 
have found pituitary extract of value 
in paralytic distention of the intestines. 
It never failed either in postoperative 
or other paresis if given intramuscu¬ 
larly when the intestine begins to dis¬ 
tend in 15-minim doses (0.92 c.c.), re¬ 
peated in an hour if required. The 
effect is then sustained by daily doses 
if need be. The beneficial influence of 
the injections was, as a rule, noticeable 
in a few minutes. 

Twenty-one cases illustrating the fact 
that pituitary extract has a very marked 
effect upon the muscular coats of the 
bowel, and that it is able to overcome 
the temporary paralysis due to ex¬ 
posure after abdominal operations. 
This is shown by the early passage 
of flatus and by the absence of ab¬ 
dominal discomfort. In only 3 cases 
did the bowels act without the assist¬ 
ance of the enema, but in every case 
except 2 a satisfactory action of the 
bowels was obtained after a simple 
enema, and it was unnecessary to give 
any aperient by the mouth. L. A. 
Bidwell (Clinical Journal, Sept. 6, 
1911). 

In postoperative cases, often as a 
routine procedure, the writer found 
pituitrin very beneficial in starting in¬ 
testinal activity as an aid to enemata 
or drugs given by mouth; repeated 
hypodermic injections often overcame 


symptoms simulating intestinal par¬ 
esis. S. W. handler (Med. Rec., Feb. 
12, 1916). 

Good results were obtained by the 
writer from pituitary extract in the 
cases of intestinal paralysis fre¬ 
quently following operations for 
acute appendicitis with general peri¬ 
tonitis. In some of these intestinal 
paralysis is the only manifestation of 
the peritoneal inflammation, and at 
times the patient’s life might be 
saved if the paralysis were overcome. 
In a case of gangrenous appendicitis 
in a child of 10 years, with marked 
abdominal distention and absence of 
bowel movements for 6 days after the 
operation in spite of gastric lavage, 
enemas, and castor oil suppositories, 
a first subcutaneous injection of 1 c.c. 
(16 minims) of pituitary extract 
(posterior lobe) brought colicky pains 
and a small stool within 15 minutes. 
Further injections on subsequent 
days were promptly followed by in¬ 
creasingly copious bowel movements, 
and recovery took place. In another 
case, that of a soldier suffering from 
intestinal occlusion, whose bowels 
had not moved 16 days, equally good 
results were obtained. E. Kirmisson 
(Bull, de I’Acad. de med., Jan. 29, 
1918). 

To prevent postoperative nausea, 
vomiting, and gas pains following ab¬ 
dominal operations the writers recom¬ 
mend pituitrin hypodermically. The 
method used is as follows: Mor¬ 
phine, Vq grain (0.01 Gm.) and atro¬ 
pine, i/iso grain (0.00035 Gm.), hypo¬ 
dermically 1 hour before operation. 
Immediately after operation they give 
1 c.c. (16 minims) of pituitrin hypo¬ 
dermically. This same dose is re¬ 
peated in 2 hours. Two hours later, 

c.c. (8 minims), and 4 hours later* 
another 54 c.c. (8 minims). Where 
too much handling of the viscera has 
not occurred, no more pituitrin is 
given, but in severe operations, doses 
of 54 c.c. (8 minims) are continued 
every 4 hours for 24 hours. They 
give 3 grains (0.2 Gm.) of calomel in 
54-grain (0.032 Gm.) doses every 54 
hour, followed by a saline cathartic. 


ANIMAL EXTRACTS (SAJOUS). 


773 


On the basis of 126 cases, of which 
104 were non-septic, 22 septic, and 9 
cases of eclampsia, the writers con¬ 
clude as follows; (1) Pituitrin is a 
valuable drug in stimulating the mus¬ 
cular coat of the intestine after ab¬ 
dominal section in non-septic cases. 
(2) It is of decided aid in preventing 
postoperative shock in non-septic 
cases of abdominal section, as evi¬ 
denced by lack of rise of tempera¬ 
ture or pulse-rate. (3) It does not 
appear to have any influence in cases 
complicated with septic peritonitis. 
(4) It stimulates the secretory activ¬ 
ity of the kidneys in eclampsia. (5) 
It materially reduces the postopera¬ 
tive suffering. Davis and Owens 
(New Orleans Med. and Surg. Jour., 
Ixx, 712, 1918). 

Pituitary gland is also of value in the 
intestinal paresis following pelvic op¬ 
erations. 

ORCHITIC OR TESTICULAR 
ORGANOTHERAPY; SPERMIN. 

The mode of action of these agents 
has not as yet been explained otherwise 
than by the process I have suggested, 
viz., that it is similar to that of the 
adrenal products, owing to the pres¬ 
ence in these preparations of the adre¬ 
nal principle. 

That the testicle influences power¬ 
fully the organism at large is well 
shown by the fact that castration be¬ 
fore puberty modifies in many partic¬ 
ulars the development of the individual. 
They preserve to a certain extent the 
characteristics of infantilism, the skin 
remaining soft and white, their muscles 
flabby and weak, and the voice high- 
pitched. Yet they are usually tall, ow¬ 
ing to inordinate growth of the bones. 
They lack courage, initiative, and in¬ 
telligence. It is evident, therefore, that 
the testicles do not solely carry on gen¬ 
ital functions. Brown-Sequard, in fact, 
taught that they carried on a dual role: 


1, procreation; 2, the production of 
an internal secretion which stimulates 
and sustains the energy of the nerve- 
centers and cord, and capable, more¬ 
over, of endowing the individual with 
physical, moral, and intellectual char¬ 
acteristics of sex. His own physical 
and intellectual activity having been 
greatly improved at the age of 72 years, 
by injections of an extract prepared 
from the testes of young dogs, he con¬ 
cluded that it possessed marked thera¬ 
peutic value. No one who, as I did, 
saw Brown-Sequard before and after 
he had submitted himself to this treat¬ 
ment could stretch his imagination suf¬ 
ficiently to attribute the change in his 
appearance to autosuggestion. He lit¬ 
erally looked twenty years younger. 
Unfortunately, the value of testicular 
preparations was exaggerated by many 
observers to such a degree that their 
use fell into disrepute, and the subject 
has received but little attention in re¬ 
cent years. 

The prevailing opinion at the present 
time is that the beneficial effects ob¬ 
tained from testicular preparations are 
not due necessarily to an internal secre¬ 
tion, though the existence of such is 
not denied, but to nucleoalbumins, sub¬ 
stances that are rich in phosphorus, re¬ 
sembling greatly lecithins and glycero¬ 
phosphates. 

In a eunuchoid studied by the 
writer the height was below the aver¬ 
age in relation to body weight, while 
lymphocytosis was insufficient. But 
there was no change in the sympa¬ 
thetic or autonomous excitability; 
the conditions of metabolism were 
normal; there was no disturbance 
of oxidation; no alimentary glyco¬ 
suria nor hydruria. E. Voelckel 
(Berl. klin. Woch., Apr. 15, 1918). 

A personal analytic study of the 
question brought out a suggestive 


774 


ANIMAL EXTRACTS (SAJOUS). 


fact, viz., that “spermin,” which may 
be obtained not only from testicles, 
but from the ovaries of mammals 
and fish roes, presents the character¬ 
istics of the adrenal secretion, both 
as to composition and physiological 
action. As I pointed out in 1903 (see 
“Adrenal Extract,’' supra), the adre¬ 
nal secretion serves to take up the 
oxygen of the air and carry it to 
all parts of the body as the active 
constituent of hemoglobin. As such it 
sustains oxidation and metabolism. 
Now, Batty Shaw (“Organotherapy,” 
1st ed., p. 205, 1905) writes: “Spermin 
possesses the very curious property of 
being an oxygen carrier, and, according 
to Poehl, is responsible for those in¬ 
ternal oxidations which take place in 
the body-tissues. Again, I have urged 
that the adrenal secretion carries on 
its oxygenizing function catalytically as 
a ferment. Pantchenko (reprint from 
Trib. medicale, 1896) states that 
“spermin acts catalytically, thus in¬ 
creasing the oxidizing power of the 
blood, and simultaneously activates 
the intraorganic oxidation processes 
where these are weakened.” More¬ 
over, as is the case with the active 
adrenal secretion, spermin gives the 
guaiac and Florence hemin test 
(Mari) ; it is, as a constituent of or- 
chitic extract, unaltered by boiling 
(Dixon); it increases the force and 
regularity of the heart much as 
does digitalis (McCarthy) ; it enhances 
the resistance to disease; it increases 
the production of urea; it acts directly 
upon the cardiovascular system. More¬ 
over, as shown by Poehl—a fact which 
indicates that it is not specific to the 
testis—it is a ubiquitous constituent of 
the whole organism, in the female as 
well as the male. 

Poehl having found in 1895 (Zeit. f. 


klin. Med., Bd. xxvi, H. 1 u. 2) that 
spermin was present in all the differ¬ 
ent parts of the organism, it becomes 
a question whether its actual source 
is the testicle, as believed by him, or 
whether, as I hold, it is derived from 
the adrenals, the testicles being richly 
supplied with it only because of the 
importance of their functions, i.e., pro¬ 
creation. The relative importance of 
both sets of organs to life answers this 
question. If, as Poehl says, “it is the 
oxidizing action of spermin which 
plays the principal role in the phenom¬ 
ena it produces,” the organs whose re¬ 
moval arrests oxidation sufficiently to 
render life impossible must be the 
source of the oxidizing agent. As is 
well known, removal of the testicles 
does not kill, while death invariably 
follows extirpation of both adrenals. 
It is plain, therefore, that the testicles 
do not produce the oxidizing substance 
shown by Poehl and others to be the 
active agent in spermin, and that it is 
the oxygen-laden adrenal secretion 
(adrenoxidase) it contains which en¬ 
dows it with therapeutic properties. 

On the whole, the foregoing facts 
have shown that, while, as held by 
Dixon, orchitic extract is a compound 
of phosphorus-laden bodies, nucleins, 
lecithin, etc., which acts much as do 
glycerophosphates and similar products 
(though containing spermin in rel¬ 
atively small quantities), spermin owes 
its beneficial effects to the fact that it 
is rich in oxygenized adrenal secretion, 
i.e., the product I have termed adren¬ 
oxidase. 

After much experimentation at the 
College de France, the writers were 
able to cause healing of extensive 
and deep wounds in a few days, by 
applying locally the pulp of sex 
glands procured by castrating young 
animals. The cells of these glands, 


ANIMAL EXTRACTS (SAJOUS). 


775 


through the secretion they contain 
and which is absorbed by, the wound, 
exert an intense accelerating action 
on the process of granulation. The 
organ found most effectual in these 
experiments would, a priori, have 
been considered that most suitable, 
owing to its especial vital energy. 
Animals deprived of these organs are 
known to accumulate fat at the ex¬ 
pense of their muscles and to be¬ 
come apathetic and passive. In the 
wounds treated with this material, its 
use often had to be discontinued after 
a few day’s in order not to exceed the 
results sought and cause projection 
of new tissue beyond the level of the 
wound cavity by reason of a too in¬ 
tense development of granulations. 
With the aid of this treatment its 
sponsors hope to spare the wounded 
long months of suffering and con¬ 
siderably shorten their stay in 
hospitals. Voronoff and Bostwick 
(Presse med.. Sept. 9, 1918). 

THERAPEUTICS— The fact that 
testicular preparations, including 
spermin, have been recommended in 
a large number of disorders has not 
served to recommend them to the im¬ 
partial observer. The use of orchitic 
extract was extolled in various nerv¬ 
ous disorders, especially tabes, neu¬ 
rasthenia, melancholia, impotence, and 
paralysis agitans; in several cutane¬ 
ous disorders, eczema and psoriasis; 
in disorders of nutrition, gout, obesity, 
and glycosuria; but others again have 
failed to obtain any favorable results. 
Spermin has also been recommended 
by Poehl and his followers not only 
in the majority of the foregoing dis¬ 
orders, but in many others besides, m 
acne, rheumatism, syphilis,marasmus, 
and in various infections, such as 
typhoid fever, diphtheria, and even 
cholera. It has been tried in Addi¬ 
son’s disease, but adrenal prepara¬ 
tions are to be preferred. 


Emulsions of sex glands are avail¬ 
able sources of material for hormone 
therapy. The essential sex hormone 
is a powerful physiological cell 
stimulant and nutrient. The writer 
recommends it for the treatment of 
early stages of arteriosclerosis, nutri¬ 
tional diseases and certain functional 
neuroses. Lydston (Jour. Amer. 
Med. Assoc., May 13, 1916). 

In the light of the analysis submit¬ 
ted above, however, there is good 
ground for the belief that beneficial 
effects were obtained in all these mala¬ 
dies. That the nucleoalbumins of 
orchitic extract, acting as would glyc¬ 
erophosphates, could be beneficial in 
the disorders enumerated, no one can 
deny. This can hardly be said, how¬ 
ever, of the cutaneous and nutritional 
disorders, unless the spermin the ex¬ 
tract contains, by enhancing oxidation 
and the destruction of toxic wastes, 
proves to be the active agent. Spermin 
itself—as adrenoxidase—is unquestion¬ 
ably capable of doing this actively, and 
in syphilis and marasmus of markedly 
enhancing the functional activity of all 
tissues. Again, the beneficial role of 
spermin in infections finds its expla¬ 
nation in a fact I have repeatedly 
emphasized, viz., that the oxygenized 
adrenal secretion, the active agent of 
spermin from my viewpoint, is an ac¬ 
tive participant in all immunizing 
processes, local and general. 

The main point to determine, how¬ 
ever, is whether orchitic extract or 
spermin affords better or as good re¬ 
sults in any of the disorders enumer¬ 
ated than other remedies at our dis¬ 
posal. The evidence available indicates 
that such is not the case. Hence, the dis¬ 
use into which the testicular products 
have fallen. 

OVARIAN ORGANOTHERAPY. 

—The ovaries correspond in many 


776 


ANIMAL EXTRACTS (SAJOUS). 


ways with the testes in their influence 
upon general development: their re¬ 
moval in children causes them to grow 
up without feminine attributes; absence 
of these organs prevents development 
of the uterus and the appearance of 
menstruation; their removal after pu¬ 
berty arrests menstruation and leads to 
atrophy of the genital organs. These 
phenomena were attributed by Cura- 
tulo, in accord with Brown-Sequard’s 
doctrine, to the loss of what influence 
an internal secretion supplied by the 
ovaries to the body at large possessed 
over its development. The administra¬ 
tion of ovarian substance in subjects 
deprived of their ovaries or during the 
menopause produced a marked amel¬ 
ioration of all distressing phenomena. 

The ovarian internal secretion be¬ 
ing elaborated by the interstitial 
cells the latter probably correspond 
to the lutein cells of the theca interna 
of the atresic follicle. The inter¬ 
stitial cells of the ovary are analo¬ 
gous to the testicular interstitial cells 
of Leydig, known to elaborate an in¬ 
ternal secretion. Hence ovarian ther¬ 
apy should include at least the prod¬ 
uct of the interstitial cells. Extracts 
of ovaries of pregnant animals, with 
exclusion of the corpora lutea, proved 
superior therapeutically to extracts 
of whole ovaries of non-pregnant 
animals which included the corpus 
luteum. W. P. Graves (Trans. Amer. 
Med. Assoc.; N. Y. Med. Jour., June 
30, 1917). 

The manner in which ovarian extract 
produces its effects has remained ob¬ 
scure. As Wilcox (“Pharmacology and 
Therapeutics,” 7th ed., p. 824, 1907) 
says: “But little is known of its phar¬ 
macological action. Fresh ovarian ex¬ 
tract is said, when injected into the 
circulation in rabbits, to raise the blood- 
pressure, diminish the heart’s action, 
and slow the respiration, and when ad¬ 
ministered to the human female also 


to increase the arterial tension. In the 
castrated animal it is found to increase 
oxidation to somewhat above the nor¬ 
mal degree, but on the normal animal 
it has no such effect.” These are the 
identical effects produced by adrenal 
preparations. From my viewpoint, it 
is, in fact, owing to the presence of 
this substance—not necessarily an in¬ 
ternal secretion—in the ovaries that 
they must be attributed. There exists, 
as shown by Schafer, a close homology 
between the interstitial of the ovary 
and the same cells in the adrenals; both 
sets of organs are derived from the 
Wolffian body; ovarian extract raises 
the blood-pressure and slows the heart, 
as shown by Federoff, Jacobs, and oth¬ 
ers. Removal of the ovaries, more¬ 
over, reduces the oxygen intake 10 per 
cent., as shown by Loewy and Richter, 
while ovarian extract restores it; it 
has been, therefore, regarded as an oxi¬ 
dizing ferment. Neumann and Vas 
noted that ovarian extract enhanced 
metabolism; Senator observed that 
ovarian preparations increased diuresis 
and the excretion of urea and phos¬ 
phoric acid. Its physiological effects 
are those of adrenal preparations, there¬ 
fore, in every respect. 

Its effects on oxidation are so strik¬ 
ing, in fact, that they have been clearly 
recognized by many clinicians. “We 
are authorized to classify ovarian 
organotherapy among the oxidizing 
agents,” write Dalche and Lepinois. 
“This conclusion, it must be admitted, 
is that reached by several authors. Cur- 
atello and Tarulli believe that the in¬ 
ternal secretion of the ovaries favors 
the oxidation of phosphorized organic 
substances, hydrocarbons, and fats. 
According to Gomes, it enhances oxi¬ 
dation and hydrolysis and favors the 
elimination of phosphates. 


ANIMAL EXTRACTS (SAJOUS). 


777 


Albert Robin and Maurice Binet have 
shown that there is during menstrua¬ 
tion an increase of the respiratory ex¬ 
changes. Keller, studying the general 
exchanges, found that there was in¬ 
creased nitrogen oxidation. We have 
ourselves found that menstruation, in 
itself, enhances vital functions and 
particularly the great function of gen¬ 
eral oxidation.” Mathes noted a reduc¬ 
tion in the excretion of the phosphates, 
in women whose ovaries had been re¬ 
moved 

The ovary appears to preside in some 
way over the metabolism of inorganic 
matter, and, hence, aids in maintaining 
the composition of the blood. Thus 
when young bitches are castrated there 
is an initial reduction of the number of 
erythrocytes and amount of hemoglobin. 
Offergeld (Deut. med. Woch., June 22, 
29, 1911). 

The investigations of the writers 
sustained Loewy and Richter so far 
as the reduction in metabolism after 
castration is concerned. Removal of 
the ovaries of dogs caused an in¬ 
crease in weight by lowering metab¬ 
olism in one from 12 to 17 per cent., 
and in the other from 6 to 14 per 
cent. Murlin and Bailey (Trans. 
Amer. Gynec. Soc.; N. Y. Med. Jour., 
Aug. 11, 1917). 

PREPARATIONS AND DOSES. 

—The preparation in general use is the 
desiccated gland, available in the form 
of 2-grain tablets, which may be given 
in doses of 2 to 4 grains (0.132 to 0.26 
Gm.) twice daily. The fresh organ 
may be employed in 10- to 15- grain 
(0.6 to 1.0 Gm.) doses where the phar¬ 
maceutical product is not available. As 
the patient becomes readily habituated 
to the remedy, it is best to begin with 
small doses and to increase them grad¬ 
ually. It owes its action to the cor¬ 
pus luteum it contains. 

THERAPEUTICS.—As in the case 
of testicular preparations and spermin. 


ovarian extractives have been tried in 
a multitude of disorders with more or 
less benefit or without any whatever. 

Natural and Artificial Menopause. 
—In disorders occurring in the course 
of the physiological menopause, or 
when the latter is produced by bilateral 
oophorectomy, ovarian preparations 
have proven of considerable value in a 
large proportion of cases since Brown- 
Sequard first introduced their use. Ex¬ 
perience has shown, however, that the 
improvement lasts only as long as the 
agent is admini^stered, and that, fur¬ 
thermore, certain phenomena: the 
palpitation, trembling, and “nervous¬ 
ness,” disappear earlier than the oth¬ 
ers, i.e., the asthenia, flushes, irritabil¬ 
ity, and psychoses, though effects in 
all symptoms, including the cutaneous 
disorders—especially acne rosacea and 
eczema—are promptly realized, some¬ 
times as early as the fourth day. 

These effects are normally explained 
by the influence of the remedy on gen¬ 
eral oxidation and the improvement of 
the antitoxic functions of the blood, the 
imperfect hydrolysis of tissue wastes 
being the underlying cause of the phe¬ 
nomena other than the general asthenia. 

The best results are obtained in 
young women who have grown obese 
after removal of the ovaries, or in 
whom obesity is due to ovarian in¬ 
sufficiency. In physiological meno¬ 
pause they are less marked, as a rule, 
and sometimes fail altogether to ap¬ 
pear. In such instances, good results 
may sometimes be obtained by giving 
simultaneously 1 grain (0.066 Gm.) 
desiccated thyroid, or by depending 
upon the latter remedy alone. In the 
amenorrhea of congenital ovarian in¬ 
sufficiency, desiccated ovary has caused 
the appearance of menstruation. 

W. E. Dixon, of Cambridge Univer- 


778 


ANIMAL EXTRACTS (SAJOUS). 


sity, recalls that the presence of ovarian 
tissue in the body, however small in 
amount, is sufficient to prevent the dis¬ 
tressing symptoms which frequently 
follow complete extirpation; even trans¬ 
planted ovaries are sometimes able to 
prevent the menopause attending re¬ 
moval of the ovaries. Hence, the ben¬ 
eficial effects of ovarian preparations. 

Improvement has also been ob¬ 
tained by some observers in acne, 
prurigo, and eczema. They have been 
found to cause an increase of the red 
corpuscles in chlorosis and to afford 
benefit in gout, epilepsy, exophthal¬ 
mic goiter and obesity, and also in 
dysmenorrhea. 

One must give an active prepara¬ 
tion in dosage sufficient for results, 
i.e., until the symptoms disappear. 
He had good results combating high 
blood-pressure at the climacteric, and 
arteriosclerosis may be thus pre¬ 
vented. All cases with hypofunction 
of the ovary are indications, espe¬ 
cially amenorrhea and so-called lacta¬ 
tion atrophy. In dysmenorrhea it is 
indicated if all other measures fail; 
likewise in hyperemesis, psychoses, 
especially dementia precox, postpuer- 
peral depression and hyperexcita¬ 
bility. C. B, Bucura (Jahrb, f. Psy- 
chiat. u. Neurol., xxxvi, 1916). 

In 2 cases of kraurosis vulvae, per¬ 
manent relief was obtained in 1 with 
ovarian extract; the other was tem¬ 
porarily improved after injecting the 
latter. The sole criterion was a 
change from the dry glistening un¬ 
yielding tissue to a soft, moist, and 
pinkish mucosa, which bore no evi¬ 
dence of scratching. G. Gellhorn 
(Trans. Amer. Gynec. Soc.; N. Y. 
Med. Jour., Aug. 11, 1917). 

Of late, the general attention has 
been centered upon the therapeutic use 
of the essential structure of the ovary, 
the corpus luteum, although Graves and 
others have emphasized also the impor¬ 
tance of the interstitial cells. 


CORPUS LUTEUM ORGANO¬ 
THERAPY. 

The consensus of opinion up to now 
has been that the internal secretion 
of the ovary is produced by the corpus 
luteum. The function of the corpora 
lutea in the early stages of their life 
is to initiate growth processes in the 
uterine cavity by means of this internal 
secretion and subsequently to preside 
over the nidation and development of 
the ovum, and the cyclic engorgement 
preceding menstruation. The labors of 
Fraenkel confirming his previous inves¬ 
tigations have strongly sustained the’ 
internal secretion theory and its con¬ 
trolling influence over the above func¬ 
tions. 

The 2 most important prerequisites 
to success in the use of this drug are: 
1. The selection of a preparation 
made exclusively from the corpora 
lutea of pregnant animals, and, 2, due 
attention to the fact that the action 
of the drug is frequently slow in as¬ 
serting itself, and that the drug 
should be given up only when thor¬ 
ough trial has demonstrated its lack 
of efficiency. L. T. de M, Sajous 
(N. Y. Med. Jour., Jan. 29, 1916). 

The relationship between character 
and degree of lutein structure to the 
disorders of menstruation, such as 
metrorrhagia and menorrhagia, was 
recently studied by the writer in 137 
cases. The corpus luteum, he says, 
should be studied from the standpoint 
of origin in the lutein cells. Cases 
of amenorrhea show characteristically 
corpora lutea. It is absent in young 
girls and in the fetus, also in the 
menopause. With amenorrhea of lac¬ 
tation it is present, the functioning 
breast probably presenting an in¬ 
hibiting secretion. In metrorrhagia 
and menorrhagia there were negative 
findings and no histological changes 
could be found connected with men¬ 
strual disturbances. The theca in¬ 
terna instead of advancing from 
lutein cells simply regresses. The 


ANIMAL EXTRACTS (SAJOUS). 


779 


granulosa cells are formed before the 
lutein cells, and the latter are formed 
from them. The internal secretion 
goes back into the blood. Hence the 
vascularization. E. Novak (Med. 
Rec., June 17, 1916). 

Summarizing the labors of Fraen- 
kel, Loeb, and Novak, the writer con¬ 
cludes that the corpus luteum makes 
possible the formation of maternal 
placenta by supplying a sensitizing 
substance to the uterine mucosa. Fix¬ 
ation of the embryo is aided by the 
activity of the corpora lutea. The 
corpus luteum is apparently essential 
for the development of the embryo 
early in pregnancy. The presence of 
corpora lutea militates against ovula¬ 
tion, i.c., lengthens the sexual cycle, 
at least in the guinea-pig. The pres¬ 
ence or absence of corpora lutea 
means presence or absence of men¬ 
struation, and possibly their hypo- or 
hyper- function means, in part at 
least, dysmenorrhea or menorrhagia. 
The activity of lutean secretion af¬ 
fects development of the mammary 
gland, even to free secretion of milk. 
E. T. Hermann (Minn. Med., May, 
1918). 

As to the manner in which the sensi¬ 
tizing substance referred produces its 
effects, it is not explained. From my 
viewpoint they are the result of the 
presence in the corpus luteum of an 
energizing principle similar to the ad¬ 
renal active principle in organic com¬ 
bination with highly specialized specific 
nucleins. 

PREPARATIONS AND 
DOSES.—The preparations available 
include desiccated corpus luteum 
{glandulcc liitece desiccates), which may 
be given in 5- to 10- grain (0.3 to 0.6 
Gm.) doses three times daily. It is 
usually administered before meals, but 
if, as is sometimes the case, it causes 
gastric disturbances it may be admin¬ 
istered during, that is to say, in .the 
course of, the meal. The term “lutein” 


is sometimes applied to the same prod¬ 
uct, but it is misleading, and its use 
should be discouraged. 

Considerable personal experience 
showed that corpus luteum should be 
given in sufficient doses, and over a 
long period of time to accomplish 
satisfactory results. It produces no 
toxic effect except a feeling of full¬ 
ness in the head or vertigo, and its 
action is not cumulative. H. E. Hap- 
pel (Med. Rec., May 19, 1917). 

A liquid preparation of corpus 
luteum extract is also available, 1 c.c. 
(16 minims) of which represents 20 
milligrams (% grain) of the dried 
substance. 

THERAPEUTICS. —The indica¬ 
tions for desiccated luteum are similar 
to those for ovarian preparations. 

It is generally regarded as superior 
to them, however, particularly for the 
nervous phenomena of menopause, 
natural as well as operative, irregular 
or scanty menstruation particularly if 
accompanied by neurasthenia, dys¬ 
menorrhea, sexual anesthesia, pru¬ 
ritus vulvae and infantile uterus. 

The writer i»ses an extract derived 
from the ovaries of pregnant animals. 
He gives 5-grain doses (0.3 Gm.) 3 
times every day. The blood-pressure 
of the patient should not be allowed 
to fall more than 15 mm, below the 
patient’s normal pressure, and never 
below 90 mm. The particular condi¬ 
tions for which the drug is found 
serviceable are: Functional amenor¬ 
rhea or scanty menstruation; dys¬ 
menorrhea of ovarian origin; mani¬ 
festations of physiologic or artificial 
menopause, such as nervous or 
congestive disturbances of reflex 
origin (hot flushes, psychoneuroses, 
etc.), “neurasthenic” symptoms dur¬ 
ing menstrual life; sterility, not due 
to pyogenic infections or mechanical 
obstructions; where the function of 1 
ovary is impaired, or 1 ovary has 
been removed, and the compensatory 


780 


ANIMAL EXTRACTS (SAJOUS). 


activity of the other is insufficient; 
repeated abortions, not due to disease 
or mechanical factors, and hyper¬ 
emesis in early pregnancy. W. T. 
Dannreuther (Jour. Amer. Med. As¬ 
soc., Jan. 31, 1914). 

Autotransplantation of the corpus 
luteum was resorted to by the writer 
in 2 cases. Both women complained 
of nausea and vomiting for several 
days after operation. In neither case 
was the implanted body palpable in 
the broad ligament at a later opera¬ 
tion. DeLee (Surg., Gynec. and Ob- 
stet., Jan., 1916). 

* In menstrual epistaxis all styptic 
agents, even in local application, are 
contraindicated; the medication of 
choice should be physiological; that 
is to say, the secretions of the cor¬ 
pus luteum. The writer gives hypo¬ 
dermic injections of this substance 
and this treatment has generally been 
found sufficient for controlling even 
the most severe types of menstrual 
epistaxis. Bab (Munch, med. Woch., 

. Nov. 13, 1917). 

Menopause symptoms of ovarian 
extirpation are largely ameliorated 
by ovarian extract. Its symptoms are 
vasomotor disturbances, hot flashes, 
head flushings, indigestion (perhaps 
due also to circulatory disturbance), 
the addition of weight mostly in the 
form of fat, sometimes nervous irri¬ 
tability, sleeplessness or the reverse, 
i.e., unusual daytime drowsiness and 
mental sluggishness. How many of 
these symptoms are due to loss of 
ovarian secretion, or to the sudden 
cessation of menstruation without 
pregnancy and consequently a stor¬ 
ing in the system without physio¬ 
logical need of the nutriments and 
salts of the blood which were pre¬ 
viously lost, has not been determined, 
but both are factors in the condition. 
The normal menopause or the cessa¬ 
tion of menstruation without preg¬ 
nancy at a younger age will cause 
more or less symptoms and ovarian 
feeding may markedly improve the 
condition. 

The writer considers the use of 
ovarian extracts in the following con¬ 


ditions: (1) after extirpation of the 
ovaries;. (2) for menopause symp¬ 
toms, especially when the onset is 
abrupt; (3) for too slowly developing 
girls; (4) when there is an apparent 
subsecretion of the ovaries in older 
girls and women, especially when a 
long course of treatment is neces¬ 
sary; (5) in menstrual disturbances. 
He discusses the results obtained. 
He also records his results in the use 
of corpus luteum in: (1) amenor¬ 
rhea; (2) overweight; (3) dysmenor¬ 
rhea; (4) pregnancy; (5) menopause 
cases. 

It is unimportant whether it is the 
ovarian substance or the corpus 
luteum that furnishes the secretion 
that is most necessary for the mature 
woman’s mental and physical health; 
it is a fact that many internal secre¬ 
ting glands are disturbed by the re¬ 
moval of the ovaries. Total removal 
of the ovarian tissue before puberty 
stops the development of the genital 
organs and of the breasts. Total re¬ 
moval after puberty stops menstrua¬ 
tion, causes artificial menopause, and 
multiplies the menopause symptoms 
and disturbances.. The younger the 
adult woman so castrated, the more 
serious are the symptoms. Castrated 
women are often left in a serious 
mental and physical condition. Feed¬ 
ing these sufferers ovarian and corpus 
luteum extracts is only partially suc¬ 
cessful in ameliorating their condi¬ 
tion. 

The rules for operation for tubal 
and ovarian disease should be: 1. As 
much of the ovaries as are found 
healthy should be left. 2. If the op¬ 
eration of necessity destroys the cir¬ 
culation and therefore nutrition of 
the whole of both ovaries, large 
grafts from the healthy part of the 
ovaries should be placed in some loca¬ 
tion that will allow the ovarian tis¬ 
sue to readily obtain a blood supply 
and therefore live. If the ovarian 
transplant lives and functions, it 
should bo remembered that it period¬ 
ically swells, and hence, in tense, non- 
dilatable tissue, may cause severe 
pain. The uterine wall, the peri- 


ANIMAL EXTRACTS (SAJOUS). 


781 


toneum, the labia majora, the mons 
veneris, the abdominal wall, and even 
the axilla have all been suggested as 
regions for implantation. 

If there is no healthy ovarian tis¬ 
sue for autografting, since total ex¬ 
tirpation of both diseased ovaries is 
not an emergency operation, the sur¬ 
geon connected with a large hospital 
generally could obtain a piece of 
healthy ovary from a non-syphilitic 
and non-tuberculous patient for trans¬ 
plantation into the woman to be cas¬ 
trated. The necessity for obtaining 
such ovarian tissue would be rare, as 
total extirpation is rarely needed. Of 
course the surgeon cannot decide that 
there is no healthy ovarian tissue 
until the time of the operation, but 
he should be prepared for such an 
emergency when there is a probability 
of the necessity of total extirpation. 
Ovaries removed from healthy women 
after sudden accidental death, and 
properly preserved, would seem to 
be ideal tissue. 

If these engrafted ovaries or 
ovarian tissues live and function, it 
may be 2 or 3 months before the fact 
is known by any symptoms or signs 
in the patient. The signs of success 
are a general feeling of health, ab¬ 
sence or diminution of menopause 
symptoms, and menstruation. Such 
grafts may live for a time and then 
die, but more or less embryonic 
ovarian tissue may have had time to 
mature and to begin to furnish the 
secretion so much needed by the 
patient. 

Properly selected patients, who 
have had their ovaries removed for 
disease and who have psychoses 
which are not cured by the adminis¬ 
tration of organic extracts, might 
well be treated by grafts of healthy 
human ovarian substance. O. T. Os¬ 
borne (N. Y. Med. Jour., cviii, 447, 
1918). 

The writer used the liquid luteum 
extract hypodermically in 2 cases of 
repeated abortion without demon¬ 
strable cause with a successful result 
in both instances. The liquid extract 
was given intramuscularly in 1-c.c. 


(16 minim) doses, 36 being given the 
one case over a period of 2 months, 
and 32 in the second case over a 
period of 9 weeks. In one the 4 
previous pregnancies had never gone 
beyond 314 months, while in the first 
case, the several abortions had re¬ 
curred about the third month. Such 
cases are referred to in text-books as 
“irritable uterus,” but the writer ten¬ 
tatively attributes the repeated abor¬ 
tions to untimely absorption of the 
corpus luteum. J. Cooke Hirst 
(Amer. Jour, of Obstet., Apr., 1918). 

Through the use of corpus luteum 
there is a tendency in the body to 
retain nitrogen and put on flesh; it 
has a marked vasodilator effect; the 
development of the mammary gland 
depends upon the formation of cor¬ 
pus luteum; the fixation of the em¬ 
bryo, the formation of the decidua 
and menstruation depends upon the 
secretion of the corpus luteum. Ex¬ 
tracts of corpus luteum, however, do 
not replace the function of the nor¬ 
mal gland. It is a true puberty gland 
and an antagonist of the pituitary. 
Extract of corpus luteum causes dim¬ 
inution of nitrogen excretion in the 
urine, diminution of oxygen absorp¬ 
tion, unstable output of carbon diox¬ 
ide, increased activity of sweat glands, 
and a marked fall in blood-pressure. 
With these physiological data on 
hand, extract of corpus luteum has 
been used by clinicians in syndromes 
believed to be caused by disturbed 
sexual gland activity. The writer has 
tried it in the so-called “nervous syn¬ 
dromes” associated with disturbed 
sexual gland function, and he care¬ 
fully watched the therapeutic results 
in a selected number of type cases. 
Satisfactory results were obtained 
and, in most instances, very rapidly 
in menstruation insanity? mild *manic 
depressive insanity; menstruation 
psychosis; headaches occurring with 
menstrual disturbance; and symp¬ 
toms of diminution of hydrochloric 
acid with menstrual disturbance. 
There were no results in menstrual 
disturbance due to obstruction; in 
menopause due to surgery; cessation 


ANIMAL EXTRACTS (SAJOUS). 


of menstruation with symptoms of 
acromegaly; in hysteria; or in or¬ 
ganic nervous disease. The clinical 
data following upon these observa 
tions were: 1, corpus luteum extract 
was effective only in the female; 2, 
it acted best when there was reason 
to believe the native corpus luteum 
was still present; 3, the administra¬ 
tion of the extract could not replace 
the function of the native corpus 
luteum in pregnancy^ and probably 
also not in menstruation; 4, when 
menstruation was discontinued by 
virtue of disturbance in the secretion 
of another gland, corpus luteum 
would not produce menstruation; 5, 
its action was more or less prompt 
and small doses were effective; and 6, 
corpus luteum extract, when effective, 
produced almost always the same 
chain of phenomena. H. Climenko 
(Trans. N. Y. Phys. Assoc.; N. Y. 
Med. Jour., Feb. 15, 1919). 

Corpus luteum has been said to 
have caused a fall in blood-pressure, 
it does so in certain cases; in which 
absence of corpus luteum causes in¬ 
creased pressure. In abnormal cases, 
those deficient in corpus luteum, cor¬ 
pus luteum extract is helpful. In 
those cases in which corpus luteum 
is not the crucial factor, corpus 
luteum extract does nothing. It is an 
extension of the principle of nature 
that one can restore a disturbed cell 
to normal function more readily than 
one can put a normal cell into dis¬ 
function—the tendency of nature to 
self repair. Corpus luteum bears a 
similar relation to blood-pressure as 
does adrenalin. Whether one gets a 
rise or a fall of blood-pressure de¬ 
pends on the quantity given. Usu¬ 
ally the result is a fall. 

,One very certain type of individual 
in whom corpus luteum has given 
more or less success as a therapeutic 
agent is a type of girl with certain 
masculine features; a slight tendency 
to a mustache, pubic hair growing to 
the umbilicus, etc. In those cases 
corpus luteum is almost invariably of 
service^ In administering a glandular 
product, one is dealing with an en¬ 


zyme which acts by catalysis, not one 
which entered into combination with 
various metabolic processes, but 
helps metabolic processes along by 
its mere presence so that in adminis¬ 
tering it, Ut is sufficient to give it 
perhaps at times, only one day in 
seven, and not necessarily daily. 
Walter Timme (N. Y. Phys. Assoc.; 
N. y! Med. Jour., Feb. 15, 1919). 

The reason that the writer did not 
meet with much success was that he 
saw the patients' 10 to 15 years after 
operation, and cases neglected to that 
extent do not respond to corpus 
luteum. Some do not respond when 
treatment is administered by -the 
mouth. A. J. Rongy (N. Y. Phys. 
Assoc.; N. Y. Med. Jour., Feb. 15, 

1918) . 

The writer found corpus luteum 
tremendously over-rated as regards 
its value. 

In some types of cases he gives cor¬ 
pus luteum to do the opposite of 
what others prescribe it for. If the 
patient complains that for so many 
days before menstruation she is nerv¬ 
ous, restless and irritable, it is an in¬ 
dex of what was happening under 
the stimulus of the ripening follicle 
of the ovaries. Associated with this 
is the stimulus to the thyroid and the 
activity of the pituitary. Dysmenor¬ 
rhea is much more due to the fact that 
the pituitary is involved than any 
action of the ovaries. There is an 
interglandular upset 13 times a year. 
Many times there is no indication of 
this until after the birth of a second 
child, when glandular exhaustion 
makes a different individual. The 
writer terms this interglandular up¬ 
set “constitutional dysmenorrhea.” 
Whether congenital or acquired it 
is one of the most important indices 
of the patient’s condition. If every 
man in the medical profession were to 
pay attention to that factor, they 
would get a better idea of endocrines. 
Nine-tenths of the prescriptions in the 
next 5 years would contain endocrine 
extracts. S. W. Handler (N. Y. Phys. 
Assoc.; N. Y. Med. Jour., Feb. 15, 

1919) . 


ANIMAL EXTRACTS (SAJOUS). 


783 


KIDNEY ORGANOTHERAPY. 

Brown-Sequard, having removed the 
kidneys and caused uremia, found that 
the injection of a glycerin extract of 
kidney prolonged the life of the animals 
as compared to those in which the same 
operation was not followed by the use 
of the kidney extract. This experiment, 
which has been repeated by others, 
forms the basis of the belief that the 
kidney produces an internal secretion. 
That such a conclusion may not be 
warranted is suggested by the fact that 
the kidneys, along with some of the 
organs so far reviewed, are also rich 
in adrenal tissue—the so-called ‘‘adre¬ 
nal rests” from hypernephroma some¬ 
times develops—and that as such they 
are capable, as an active factor in the 
immunizing functions of the body, of 
counteracting temporarily the toxemia 
or “uremia” brought on by removal of 
the kidneys. Indeed, the relief afiforded 
is but ephemeral, death being post¬ 
poned but one or two days in rabbits, 
in which Bitzou repeated Brown-Se- 
quard’s experiments. Dromain and de 
Pradel Bra had also noticed that injec¬ 
tions of kidney extract lessened the fits 
of epilepsy, another toxemia. Dubois 
and Renaut have already, in fact, at¬ 
tributed antitoxic power to kidney ex 
tracts. 

That we are again dealing mainly 
with a manifestation of the adrenal 
principle is further suggested by its 
powerful blood-pressure-raising prop¬ 
erty. Tigerstedt and Bergman found 
that rennin possessed this power; Bin- 
gel and Strauss recently confirmed their 
observation, and found that its action 
corresponded with that of adrenal and 
pituitary extracts, those of other or¬ 
gans causing depressor eflfects. The 
use of pressure produced by kidney ex¬ 
tract was high, i.e., from 40 to 60 mm. 


Hg, and lasted from fifteen to thirty 
minutes. The authors concluded, more¬ 
over, that “the action of rennin, like 
that of adrenalin, is exerted in the mus¬ 
cles of the peripheral vessels.” Its gen¬ 
eral action, however, is more like that 
of pituitary body extract, the adrenal 
principle being doubtless combined or¬ 
ganically, as in the pituitary, with 
bodies which prolong and perhaps con¬ 
trol advantageously the action of the 
former. Like adrenal preparations kid¬ 
ney extract also produces myosis. 

Even the oxidizing power I have at¬ 
tributed to the adrenal secretion seems 
to be reproduced; Batty Shaw, who 
also finds “very little justification for 
the existence of an internal secretion” 
in the kidney, remarks that “possibly 
nephrin and other renal preparations 
provide a means of stimulating oxida¬ 
tion in general, the kidney merely shar¬ 
ing in this oxidation”—a very accurate 
estimate from my viewpoint. Shaw 
adds, moreover, that “similar good re¬ 
sults have been reported as a result of 
treatment by means of spermin and 
testicular extract,” both of which, as I 
have shown, also owe, in all probabil¬ 
ity, their therapeutic effects to the adre¬ 
nal principle they contain. 

THERAPEUTICS AND DOSE. 
—The therapeutic application of kid¬ 
ney preparations has received consid¬ 
erable attention, and favorable results 
have been reported in about one-half 
of the cases of chronic nephritis, or 
Bright’s disease, in which it was tried. 
The mode of action, in the light of the 
facts submitted above, is mainly an in¬ 
crease of the antitoxic power of the 
blood and diminution, therefore, of the 
irritation of renal apparatus. Page and 
Dardelin, for example, report marked 
amelioration in 18 cases, using a mac¬ 
eration prepared as follows: A very 


784 


ANIMAL EXTRACTS (SAJOUS). 


fresh kidney from a pig is cut into 
minute pieces, washed with fresh water 
to remove the excess of urine, then 
hashed and pounded into pulp. This 
pulp is put into 300 Gm. (9 ounces and 
5 drams) of fresh water to which the 
physiological proportion of salt, 7.50 to 
1000, has been added It is then al¬ 
lowed to macerate for three hours, 
stirred occasionally, and kept in a cool 
place to avoid fermentation. The red 
water of the maceration is divided into 
three parts, to be drunk by the patient 
during the day. It is more conveniently 
given, however, in tablet form, as 
“nephritin,” prepared in this country by 
Reed and Carnrick. Only the active 
substance of the kidney is used in this 
preparation, the dose being from 10 to 
15 5-grain (0.33 Gm.) tablets daily in 
divided doses, given between meals. 

Kidney preparations have also been 
used with more or less advantage in 
puerperal intoxications and epilepsy, 
but their field is essentially the va¬ 
rious forms of nephritis, and particu¬ 
larly for the prevention of uremia. 
They also tend to increase diuresis and 
reduce the albumin. As stated above, 
however, favorable effects are to be ex¬ 
pected in about one-half of the cases. 
THYMUS ORGANOTHERAPY. 

In 1907, I submitted evidence which 
had led me to suggest that the function 
of the thymus was to supply an excess 
of phosphorus in organic combination 
during the growth of the body, i.e., 
particularly while the development of 
the osseous and nervous systems de¬ 
manded such a reserve. This was sus¬ 
tained by the recognized fact that 
certain diseases of children and ado¬ 
lescents, especially marasmus, rachitis, 
and trophic disorders of the brain and 
nervous system, were due, in part, to 
the functions of the thymus. 


The writer carried out the follow¬ 
ing experimental work. Young rab¬ 
bits belonging to the same litter were 
each trephined on the tibia. Some of 
the animals were fed on thymus 
gland, the others serving as control 
animals. The evolution of the bone 
trauma in each was controlled by 
regularly repeated radiographic ex¬ 
aminations. The writer concludes 
that the exhibition of thymus gland 
hastens regeneration of bone trau¬ 
mata. At a given time in repair the 
difference consisted in the presence of 
a smaller bone defect, a normal osse¬ 
ous configuration and a moderate cal¬ 
lus, while the control animals offered 
an inverse condition. K. Glaesner 
(Berl. med. Woch., Nov. 25, 1918). 

While this is only adduced as a work¬ 
ing theory—the thymus having been the 
graveyard of many hypotheses—all 
that can be said for it is that it seems 
to account for the clinical results ob¬ 
tained under its use better than any 
hypothesis so far advanced, besides 
corresponding with the laboratory find¬ 
ings of its effects. 

In sexually immature rabbits, frag¬ 
ments of thymus autotransplanted 
into the subcutaneous tissue of the 
abdomen after thymectomy were 
found to take, grow and survive. 
This confirms other observers’ re¬ 
sults that thymus removal hastens 
sexual maturity, and that utilization 
of rabbits for breeding hastens invo¬ 
lution of the thymus. The writers’ 
experiments apply to the transplanted 
thymus as well. Marine and Manley 
(Jour. Labor, and Clin. Med., Oct., 

1917) . 

Whatever be the real function of 
the thymus, certain it is that its pro¬ 
duction of an internal secretion has 
not been proved. The evidence in 
favor of such a theory is but circum¬ 
stantial at best and very meager. It 
is equally difficult to prove that the 
thymus does not produce a secretion. 
Hoskins (Endocrinology, July-Sept., 

1918) . 


ANIMAL EXTRACTS (SAJOUS). 785 


in me lignt or my own views the 
thymus supplies lymphocytes i.e., thy¬ 
mocytes, exceedingly rich in nucleins 
to the body at large for the purposes in¬ 
dicated, but not an internal secretion. 

THERAPEUTICS. —Diseases of 
the Thyroid. —In simple goiter it was 
first tried by Mikulicz, who obtained 
sufficiently favorable results in 5 out of 
11 cases to render operation unneces¬ 
sary, at least for the time being. Rein- 
bach considers it probably superior to 
thyroid because the unpleasant effects 
of the latter are avoided; for the same 
reason it is especially suitable when 
organotherapy has to be used contin¬ 
uously. This view is based on the em¬ 
ployment of thymus in a large number 
of cases in the Breslau clinic. Mikulicz 
gave from 2% to 4 drams (10 to 16 
Gm.) of the raw sheep thymus on 
bread three times a week, increasing 
the dose slightly if required. 

In exophthalmic goiter it had proven 
efficacious in the hands of Owen in 
advanced cases, and also in those of 
Mande when other remedies had been 
used fruitlessly. The latter gave 45 
grains (3 Gm.) daily to a severe 
case, which greatly improved, relaps¬ 
ing whenever the treatment was inter¬ 
rupted. S. Solis-Cohen also advocates 
its use in this disease, having found 
that it exerted its beneficial influence 
mainly upon the nervous symptoms of 
the disease without affecting the ex- 
ophthalmus. Huston White found that 
the nervous symptoms were alone im¬ 
proved. 

These observations coincide with my 
own view of the manner in which thy¬ 
mus gland produces its beneficial ef¬ 
fects. The excess of thyroiodase pro¬ 
duced in exophthalmic goiter causes, 
we have seen, too rapid oxidation of 
the phosphorus in organic combination 


in the tissues, particularly in those of 
the nervous system, which are ex¬ 
tremely rich in phosphorus. Thymus, 
supplying phosphorus in organic com¬ 
bination, replaces that lost by the nerv¬ 
ous system, thus procuring marked 
benefit in this one direction. As 5 
grains (0.33 Gm.) of the dried thymus 
are equivalent to 30 grains (2 Gm.) of 
the fresh gland, this dose can readily 
be given three times daily. 

Rachitis, or Rickets.—The same ex¬ 
planation, i.e., the purveying of phos¬ 
phorus in organic combination—to the 
osseous system, in the present connec¬ 
tion—accounts for the undoubted ben¬ 
efit thymus has procured in this dis¬ 
order. Mendel, having used thymus 
gland in 1^4 to 3 drams (6 to 12 Gm.) 
daily in over 100 cases, obtained marked 
benefit in a large proportion, but espe¬ 
cially in the nervous symptoms, includ¬ 
ing spasm of the glottis. It had previ¬ 
ously been tried by Stoppato, but with¬ 
out marked benefit. In Mendel’s cases 
both fresh and commercial tablets were 
tried, the cases being subdivided as fol¬ 
lows: 1, those which showed prodro¬ 
mal symptoms only; 2, those in which 
deformity of the osseous system was 
the chief feature; 3, those marked by 
spasm of the glottis, and, 4, those in 
which splenic enlargement was the most 
important sign. Marked improvement 
was noted in all after from three to 
four weeks, and dentition and the clos-^ 
lire of the fontanelle proceeded satis¬ 
factorily. No untoward symptoms were 
noted—a marked advantage over thy¬ 
roid preparations. In a case of stunted 
growth, obviously of osseous origin, 
in a boy of 14 years, R. Webb Wilcox 
obtained 9% inches growth in three 
years by the persistent use of 2 grains 
(0.13 Gm.) thymus night and morning. 

The view that these effects are due 


786 


ANIMAL EXTRACTS (SAJOUS). 


to the addition of phosphorus in organic 
combination to the body is further sus¬ 
tained by the results of experimental 
observation by Hart and Nordmann, 
that the thymus had a definite relation 
to assimilation, and that it took an' 
active part in the resistance of the or¬ 
ganism to infection. As my own inves¬ 
tigations have shown (see the second 
volume of “Internal Secretions,” page 
878), nucleoproteid, in so far as its 
phosphorus in organic combination is 
concerned, is an active participant in the 
immunizing process. 

Great relief, particularly from the 
pain of cancers, can be attained by 
the use of thymus extract, according 
to Takaki. This line of treatment 
was originally worked out by Gwyer, 
who showed that there was marked 
decrease, or even elimination, of pain. 
The glands used were received fresh. 
The fat was removed, and the glan¬ 
dular substance cut up and dried at 
a low temperature by a forced 
draught of air, then ground and sifted 
•to a uniform powder. Of this a dose 
of from 1 to 4 drams was given three 
or four times a day. Ludlam has 
recommended thymus gland in de¬ 
mentia precox {q.v.)on the basis of 
six successful cases. 

BONE-MARROW ORGANO¬ 
THERAPY 

The bone-marrow being the source 
of red corpuscles, its preparations 
have been tried in pernicious anemia, 
the secondary anemias, chlorosis, ma¬ 
laria, leucocythemia, leukemia, Hodg¬ 
kin’s disease, rickets, and other dis¬ 
orders of the osseous system. In all of 
these affections bone-marrow gave good 
results in some cases, while an equal 
number were in no way influenced. 
This obviously suggests that its indica¬ 


tions coincide with certain phases or 
stages of the disease which have not 
as yet been determined. The average 
dose is 5 grains, after meals. 

BRAIN AND NERVE SUB¬ 
STANCE ORGANOTHERAPY. 

The belief, based on pure assumption, 
that brain and nerve substance possess 
or produce an internal secretion has 
never been sustained scientifically. 

The clinical results, though quite 
discordant, particularly in the neu¬ 
roses and psychoses in which these 
preparations have been tried, have 
shown a tendency to harmonize since 
the introduction by Sciallero of an 
oily extract. Page, who has obtained 
unusually good results in neurasthe¬ 
nia by means of injections of this ex¬ 
tract, ascribes them to its antitoxic 
and antispasmodic effects. Wasser- 
mann and Takaki had previously shown 
that tetanus toxin was neutralized by 
contact with brain substance, and 
that when a fatal dose of tetanus toxin 
was injected with brain substance the 
fatal effects were prevented. The 
same observations were made in the 
case of hydrophobia by Babes; in 
strychnine and morphine poisoning 
by Widal and Nobecourt; in tetanus 
by Krokiewicz; in epilepsy by Lion, 
and also Kaplan, using Poehl’s opo- 
cerebrin—in accord with Dana’s expe¬ 
rience several years earlier. Sciallero, 
who obtained encouraging results in 
neurasthenia, hysteria, chorea, tic, 
and epilepsy, used his oily extract 
“cephalopin” in doses varying from 1 
to 5 c.c. (16 to 81 minims). No un¬ 
toward effects were obtained. 

Although it is very improbable that 
brain extracts injected into the tissues 
act as they do in the test-tube, it seems 
established that they act much as do the 
lecithins on the market, i.e., by furnish- 


ANIMAL EXTRACTS (SAJOUS). 


787 


ing phosphorus to the organism in an 
assimilable form, or as niicleoproteids 
in enhancing the immunizing process. 
Be this as it may, these substances seem 
to have produced effects which suggest 
that they should, not as yet, be set 
aside. 

The writer used brain extract in 
dementia, various forms of insanity, 
dementia precox, and melancholia, 
and other mental disorders with ma¬ 
terial improvement in some. It has 
the sedative effect of the synthetic 
hypnotics, without their danger. The 
extract used at first was prepared 
from the brains of fetal calves and 
was prepared by boiling finely-divided 
brain tissue in alcohol and ether, and 
preparing an emulsion from the de¬ 
posited material with normal saline 
solution. This extract is rich in 
cholesterin and in a substance that 
reduces Fehling’s solution. W. Maule 
Smith (Brit. Med. Jour., Nov. 23, 
1912). 

The writer recalls the discovery of 
Howell that the so-called fibrin fer¬ 
ment is not really an enzyme, but a 
lipoid. As is well known, the fibrin 
ferment prepared from blood plate¬ 
lets has hemostatic properties and is 
at present extensively employed for 
this purpose. The author has pre¬ 
pared lipoid extracts by placing the 
brains of oxen in 3 equivalents of 
alcohol, shaking and decanting. The 
residue is gently strained through 
muslin and treated with threefold the 
amount of ether, shaken violently 
and filtered through cotton and paper. 
The dried filtrate is yellow, consists 
of Thudichum’s kephalines and pos¬ 
sesses strong hemostatic properties, 
through its power of accelerating co¬ 
agulation. Hirschfelder (Berl. klin. 
Woch., Sept. 13, 1915). 

A phosphatid extracted from brain 
tissue, variously known in the litera¬ 
ture and trade as thromboplastin or 
kephalin, was tried by the writer at 
the Johns Hopkins Hospital clinics, 
to hasten coagulation and hemostasis 
after surgical operations upon the 
genito-urinary apparatus and espe¬ 


cially prostatectomy. Packing was 
impregnated with kephalin and ap¬ 
plied to the raw surfaces. There was 
practically no bleeding. The writer 
uses kephalin gauze and also coats 
catheters with it. H. L. Cecil (Jour. 
Amer. Med. Assoc., Ixviii, 628, 1917). 

MAMMARY GLAND ORGANO¬ 
THERAPY. 

It is held by some that the mammary 
gland produces an internal secretion; 
but the evidence is so scant that it can 
hardly be taken into account. 

Although mammary gland, introduced 
by Bell, of Glasgow, and in the United 
States by the late John H. Shober, has 
been used considerably, and has shown 
a marked stimulating action upon the 
uterus, the manner in which it produces 
this effect has remained obscure. An 
extract lowers somewhat, and but tem¬ 
porarily, the blood-pressure and the 
pulse. According to Shober, it dimin¬ 
ishes the blood supplied to the uterus 
and thus controls hemorrhage, its action 
resembling that of ergot, though free 
of the unpleasant effects of the latter 
drug. ' 

Mammary gland is prepared in the 
form of a tablet made of the desiccated 
gland of the sheep, each tablet repre¬ 
senting 20 grains (1.32 Gm.) of the 
fresh gland. The dose is from 3 to 6 
tablets daily. 

The therapeutic application is re¬ 
stricted to the genital apparatus. In 
cases of uterine fibroids characterized 
by excessive menorrhagia and metror¬ 
rhagia the bleeding was found by 
Shober to be controlled in a few weeks 
and the periods become regular, nor¬ 
mal, and free from pain. There is im¬ 
provement in the patient’s health and 
weight, and the turnors themselves di¬ 
minish in size up to a certain point. 
In 43 cases treated by Fedoroff, com¬ 
plete cure occurred in one-third, i.e., 


788 


ANIMAL EXTRACTS (SAJOUS). 


33 per cent.; a reduction of volume in 
43 per cent., and no result whatever in 
14 per cent. The hemorrhages disap¬ 
peared completely in 80.3 per cent, of 
the cases. According to Fedoroff, the 
best effects are obtained when the mam¬ 
mary extract is used hypodermically. 
The patient is thus placed in a better 
condition for any needed operation, and 
often the necessity for an operation is 
postponed. Where there is evidence of 
inflammatory or degenerative changes, 
or when serious pressure symptoms are 
not controlled after a reasonable trial, 
operation should not be delayed. The 
mammary gland is also useful in cases 
of subinvolution unassociated with 
malignancy or structural changes. 

Mammary gland has also given good 
results, in the hands of Pozzi, in the 
uterine hemorrhages attending metritis 
of any kind. It decongests the organ 
and thus counteracts inflammation. 

It has also been recommended to as¬ 
sist uterine involution and to enhance 
lactation in agalactia. Here, again, the 
results reported have been antagonistic. 
The dose is 5 grains (0.32 Gm.), re¬ 
peated several times daily, preferably 
after meals. 

On the plea that the exciting cause 
of uterine fibroids and the accom¬ 
panying hemorrhages is uterine hy¬ 
peremia of ovarian origin, and that 
the antagonistic effect of the mam¬ 
mary principle is helpful because of 
its anti-ovarian influence, the writer 
found that in a large proportion of 
cases receiving mammary extract, the 
menorrhagia was effectively con¬ 
trolled and under its continued use 
large uterine fibroids often disappear 
even during the early reproductive 
period. The dose of mammary sub¬ 
stance was 10 grains (0.65 Gm.), 3 
times a day; in, severe cases 1 Gm. 
(15 grains), 4 times a day may be 
given with extract of ergot 0.2 Gm. 
(3 grains) and extract of hydrastis 


0.1 Gm. (134 grains) with each dose 
and also, in some cases. X-ray to the 
ovaries every 3 weeks. W. A. Briggs 
(Endocrinology, Apr., 1917). 

SPLEEN ORGANOTHERAPY. 

This is based mainly on the prevail¬ 
ing opinion that the spleen destroys red 
corpuscles and creates new ones, and 
that it produces some .sort of immuniz¬ 
ing body, its leucocytes, as in lymph- 
glands, being phagocytic. 

Extracts of spleen have been tried 
in various disorders, including ex¬ 
ophthalmic goiter, the secondary ane¬ 
mias, pernicious anemia, chlorosis, 
lymphadenoma, and leucocythemia, 
but the results have not been such as to 
warrant further trial. Bayle recom¬ 
mends it highly in tuberculosis. 

The writer administered fresh 
spleen substance with advantage in a 
number of cases of anemia. It 
reduced the proportion of nucleated 
reds in a remarkable manner and the 
clinical experiences were paralleled 
by similar findings in experiments 
upon animals. Brinchmann (Norsk 
Mag. f. Laegevidenskaben, Nov., 
1916). 

Pancot, Carpenter, and others claim 
to have obtained good results from 
splenic extract in the treatment of 
malaria. Lemansky found that it en¬ 
hanced the action of quinine. 
HEPATIC ORGANOTHERAPY. 

Besides the functions carried on by 
the bile, which will be referred to be¬ 
low, the liver subserves several useful 
roles. It is endowed with important 
antitoxic functions, all foodstuffs ab¬ 
sorbed through the intestinal mucosa 
entering the organ through the portal 
system for this purpose. It supplies, 
out of the glycogen it forms, the blood 
and tissues the sugar they contain; it 
takes part in the metabolism of nitrog¬ 
enous substances and forms urea. That 


ANIMAL EXTRACTS (SAJOUS). 


789 


these many phases of usefulness should 
have suggested the use of hepatic sub¬ 
stance is not surprising. Gilbert and 
Carnot found it useful in various con¬ 
ditions. 

In diabetes liver extract was found 
to act with considerable energy; in some 
cases, however, the sugar was promptly 
diminished, even to nil occasionally, 
while in others it increased it. I have 
called attention to the fact that two 
forms of diabetes, the sthenic and as¬ 
thenic, should be clearly distinguished 
from each other, the treatment of one 
form being pernicious in the other. It 
is in the asthenic form that hepatic ex¬ 
tract will be found of value. Lere- 
boullet has also observed beneficial 
effects in some cases. 

One important feature of liver ther¬ 
apy is that, as emphasized by practical 
experience, the remedy causes diuresis 
in subjects who suffer from hepatic in¬ 
sufficiency in some form and par¬ 
ticularly when it occurs in the course 
of cirrhosis. The diuresis is also ac¬ 
companied by increased urea elimina¬ 
tion. 

In alcoholic cirrhosis it was also 
found of value by Gilbert and Carnot. 
The edema, jaundice, and hemorrhages 
were kept in abeyance in a case re¬ 
ported, returning whenever the use of 
liver extract was interrupted. 

The coagulating action of liver on 
the blood, shown by Gilbert and Car¬ 
not, was carefully studied by Berthe. 
The patients on whom the observations 
were made were tuberculous, and had 
suffered repeatedly from hemoptysis, 
which had not responded to any ordi¬ 
nary treatment. In all cases the results 
were rapid. The method was also tried 
in cases of epistaxis and metrorrhagia. 
The method consisted in giving an ex¬ 
tract of liver, about 3 drams (12 Gm.) 


for a dose, in tepid soup. This 
amount will in many cases suffice, but 
can be repeated when necessary. It 
can also be administered per rectum in 
the same dose. One of the best and 
most suitable preparations is the desic¬ 
cated liver. The glycerin extract is 
also, efficacious. Should it not be pos¬ 
sible to procure a ready-made extract, 
an emulsion of liver freshly prepared, 
and given in the form of an enema, 
seems to act perfectly well, 3 to 6 
ounces (94 to 186 Gm.) being finely 
chopped up and then rubbed up with 
water, about 434 ounces (140 Gm.) of 
liver being used. Fresh pigs’ liver is 
one of the best sources of preparation. 

Liver extract, now available on the 
market, has also been used with advan¬ 
tage in chronic gastrointestinal intox¬ 
ication, the object being to check the 
growth of bacterial flora. Biliary acids, 
referred to below, are, however, prefer¬ 
able. A convenient way is to use the 
biliary extract in suppositories. 

BILE, BILE-SALTS, AND BIL¬ 
IARY EXTRACTS. 

The use of bile in therapeutics is 
based on a sounder basis than that of 
several of the foregoing agents, its ex- 
citomotor action on the intestine, now 
fully demonstrated, serving various use¬ 
ful purposes. It counteracts constipa¬ 
tion due to intestinal atony, and thus 
prevents autointoxication of intestinal 
origin, which, in turn, produces cholan¬ 
gitis by allowing the return into the 
portal system of excretory products 
which should have escaped normally 
with the intestinal discharges. Again, 
bile, as shown by Pawlow, is a physio¬ 
logical auxiliary to the pancreatic juice, 
augmenting its activity threefold. As 
is well known also, bile, or gall, in¬ 
creases the solubility of cholesterin, 
thus preventing the formation of gall- 


790 


ANIMAL EXTRACTS (SAJOUS). 


stones. Bile is also endowed with anti¬ 
toxic properties. 

The therapeutic use of bile or bile 
constituents is thus based on a solid 
foundation. They may be used as 
stated above, in constipation and putre¬ 
faction due to hepatic and intestinal 
atony, autointoxication of intestinal 
origin, in cholangitis and the resulting 
jaundice, and also to prevent the for¬ 
mation of gall-stones. They have also 
been used advantageously in enteroco¬ 
litis in its membranous form. 

Mucomembranous enterocolitis and 
constipation being the result of insuffi¬ 
ciency of the biliary secretion, their 
treatment becomes simple. The general 
indications are: (1) reduction to a 
minimum of the quantity of toxic and 
putrefactive products in the intestine by 
an appropriate diet; (2) shortening of 
the period of transit of food through 
the alimentary canal and prevention of 
the coagulation of mucus by the use of 
a cholagogue, the best of which is bile 
itself. The writer uses an extract de¬ 
void of putrescible nucleoalbumins, 
which he has termed antimucose, avail¬ 
able in 0.20-Gm. (3.1 grains) dragees; 
suppositories, and ampules of 50 c.c. 
(1.7 fluidounces) in which the biliary 
substances, dissolved in water, occur in 
the concentration of normal bile. H. 


Nepper (Monthly Cyclopedia and Med. 
Bull., Jan., 1912). 

The writer found bile a powerfully 
cytolytic agent, owing to the coen¬ 
zyme or activating action of its con¬ 
stituents on the autolytic enzymes or 
processes. Whole bile was found 
more powerful though less penetrat¬ 
ing than corresponding concentra- ' 
tions of either of the bile salts. 
Tatum (Jour, of Biol. Chemistry, 
Oct, 1916). 

Although cholic acid is the most 
active of the bile-salts, salts of glyco- 
cholic or taurocholic acid are preferred. 
They possess all the therapeutic prop¬ 
erties of oxgall. The sodium glyco- 
cholate or taurocholate can be con¬ 
veniently used in to 3- grain 

(0.032 to 0.19 Gm.) doses three times 
a day. Or, the extract of bile may be 
given in 5- to 15- grain (0.32 to 1.0 
Gm.) doses after meals, with a 
draught of water. Bile may also be 
injected into the rectum to cause its 
evacuation. This is especially valu¬ 
able in paralytic ileus, postoperative 
and peritonitic atony, or paresis of the 
intestine from any cause. 

C. E. DE M. Sajous 

Philadelphia. 




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